Provider Demographics
NPI:1790775005
Name:SHANNON, HEATHER MARIAN (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIAN
Last Name:SHANNON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 ONEIDA STREET
Mailing Address - Street 2:ATTN: PAULA BAKER
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069
Mailing Address - Country:US
Mailing Address - Phone:315-598-4715
Mailing Address - Fax:315-598-4751
Practice Address - Street 1:522 S 4TH ST STE 500
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069
Practice Address - Country:US
Practice Address - Phone:315-598-4740
Practice Address - Fax:315-598-4728
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000678-1367A00000X
NY00420826363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02381762Medicaid
NY02381762Medicaid