1215250279 NPI number — MRS. SHANNON D MARZULLO ANP

Table of content: MRS. SHANNON D MARZULLO ANP (NPI 1215250279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215250279 NPI number — MRS. SHANNON D MARZULLO ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARZULLO
Provider First Name:
SHANNON
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215250279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3332 WALDEN AVE
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
DEPEW
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14043-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-849-8750
Provider Business Mailing Address Fax Number:
716-849-8757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 LAKEFRONT BLVD
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14202-4345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-849-8750
Provider Business Practice Location Address Fax Number:
716-849-8757
Provider Enumeration Date:
03/04/2010

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: 363LA2200X , with the licence number:  F305322-1 , 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: 03600295 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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