Provider Demographics
NPI:1740695303
Name:SPAIN, SHANNA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:SPAIN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W 71ST ST APT 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-3530
Mailing Address - Country:US
Mailing Address - Phone:201-207-4742
Mailing Address - Fax:
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:7 TOWER- NEONATAL INTENSIVE CARE UNIT
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:212-342-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY622025163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse