Provider Demographics
NPI:1942754015
Name:PETERS, SHELLY LYNN (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:LYNN
Last Name:PETERS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:LYNN
Other - Last Name:PANGBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:324 UNIVERSITY AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1811
Mailing Address - Country:US
Mailing Address - Phone:315-362-2540
Mailing Address - Fax:315-671-1786
Practice Address - Street 1:324 UNIVERSITY AVE FL 3
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1811
Practice Address - Country:US
Practice Address - Phone:315-362-2540
Practice Address - Fax:315-361-1786
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-06
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402033363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04532216Medicaid