1285972067 NPI number — SHANNON LEE RADACI CRNP

Table of content: SHANNON LEE RADACI CRNP (NPI 1285972067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285972067 NPI number — SHANNON LEE RADACI CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RADACI
Provider First Name:
SHANNON
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOLYNEAUX
Provider Other First Name:
SHANNON
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285972067
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1389 SAMANTHA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH HUNTINGDON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15642-5800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5609 5TH AVE
Provider Second Line Business Practice Location Address:
HEARTLAND CARE PARTNERS
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15232-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-375-5495
Provider Business Practice Location Address Fax Number:
800-564-5952
Provider Enumeration Date:
01/29/2013

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: 363L00000X , with the licence number:  SP012506 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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