Provider Demographics
NPI:1760521538
Name:MCLOUGHLIN DALEY, SHANNON (APN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MCLOUGHLIN DALEY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 E JERSEY ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07206-1261
Mailing Address - Country:US
Mailing Address - Phone:908-994-7290
Mailing Address - Fax:908-994-7054
Practice Address - Street 1:654 E JERSEY ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07206-1261
Practice Address - Country:US
Practice Address - Phone:908-994-7290
Practice Address - Fax:908-994-7054
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NCO4273800364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJS33075Medicare UPIN
NJ049832Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER