Provider Demographics
NPI:1790261543
Name:WORDEN, SHANNON LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:WORDEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LYNN
Other - Last Name:HAGGERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:35 EMPIRE STATE BLVD
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9777
Practice Address - Country:US
Practice Address - Phone:518-477-2167
Practice Address - Fax:518-477-5182
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05416091Medicaid