1164653622 NPI number — SHANNON NICOLE MEYERS FNP

Table of content: SHANNON NICOLE MEYERS FNP (NPI 1164653622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164653622 NPI number — SHANNON NICOLE MEYERS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEYERS
Provider First Name:
SHANNON
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ORTIZ
Provider Other First Name:
SHANNON
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164653622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2209 GENESEE STREET
Provider Second Line Business Mailing Address:
BUSINESS OFFICE ROOM 310
Provider Business Mailing Address City Name:
UTICA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-801-3282
Provider Business Mailing Address Fax Number:
315-801-8391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4752 COMMERCIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HARTFORD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13413-6205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-275-3046
Provider Business Practice Location Address Fax Number:
315-275-3048
Provider Enumeration Date:
07/31/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  335917 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03207650 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".