Provider Demographics
NPI:1295440089
Name:KINNE, SHANNON DAWN (LPN)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:DAWN
Last Name:KINNE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:DAWN
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 451
Mailing Address - Street 2:
Mailing Address - City:MONGAUP VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12762-0451
Mailing Address - Country:US
Mailing Address - Phone:845-707-9309
Mailing Address - Fax:
Practice Address - Street 1:15 SUFFERN PL
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-5566
Practice Address - Country:US
Practice Address - Phone:845-357-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307979164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse