Provider Demographics
NPI:1811506348
Name:VASSAR, SHANNON MARIE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:VASSAR
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 1:8 SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-3523
Mailing Address - Country:US
Mailing Address - Phone:518-570-8867
Mailing Address - Fax:
Practice Address - Street 1:20 AMPERSAND DR
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6500
Practice Address - Country:US
Practice Address - Phone:518-561-8480
Practice Address - Fax:518-566-6382
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY527060163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)