Provider Demographics
NPI:1700543972
Name:BUCCIARELLI, SHANNON (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BUCCIARELLI
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 1:1395 CHEWS LANDING RD
Mailing Address - Street 2:
Mailing Address - City:CLEMENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-2760
Mailing Address - Country:US
Mailing Address - Phone:855-239-5099
Mailing Address - Fax:
Practice Address - Street 1:1395 CHEWS LANDING RD
Practice Address - Street 2:
Practice Address - City:CLEMENTON
Practice Address - State:NJ
Practice Address - Zip Code:08021-2760
Practice Address - Country:US
Practice Address - Phone:855-239-5099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01224200363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health