Provider Demographics
NPI:1245872498
Name:KIRKNESS, SHANNON HALEY
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:HALEY
Last Name:KIRKNESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 COPE FARMS RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-3153
Mailing Address - Country:US
Mailing Address - Phone:860-810-2373
Mailing Address - Fax:
Practice Address - Street 1:4 COPE FARMS RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-3153
Practice Address - Country:US
Practice Address - Phone:860-810-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty