Provider Demographics
NPI:1982236840
Name:SHANNON, KIERAN J
Entity Type:Individual
Prefix:
First Name:KIERAN
Middle Name:J
Last Name:SHANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 WILSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1441
Mailing Address - Country:US
Mailing Address - Phone:631-672-2854
Mailing Address - Fax:
Practice Address - Street 1:3330 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-1036
Practice Address - Country:US
Practice Address - Phone:631-672-2854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032022225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty