Provider Demographics
NPI:1841923299
Name:DEGROFF, SHANNON NICOLE (LPN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:DEGROFF
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 58
Mailing Address - Street 2:
Mailing Address - City:SCHOHARIE
Mailing Address - State:NY
Mailing Address - Zip Code:12157-0058
Mailing Address - Country:US
Mailing Address - Phone:518-729-7262
Mailing Address - Fax:
Practice Address - Street 1:183 TERRACE MTN RD
Practice Address - Street 2:
Practice Address - City:SCHOHARIE
Practice Address - State:NY
Practice Address - Zip Code:12157-2412
Practice Address - Country:US
Practice Address - Phone:518-729-7261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290397164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse