1760557425 NPI number — JENNIFER J SHANAHAN R.D., C.D.N.

Table of content: JENNIFER J SHANAHAN R.D., C.D.N. (NPI 1760557425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760557425 NPI number — JENNIFER J SHANAHAN R.D., C.D.N.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANAHAN
Provider First Name:
JENNIFER
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R.D., C.D.N.
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:
1760557425
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
216 GLEN SUMMER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLBROOK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11741-5025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-472-6717
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 RESEARCH WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST SETAUKET
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11733-6401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-941-2000
Provider Business Practice Location Address Fax Number:
631-941-2010
Provider Enumeration Date:
11/21/2006

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: 133V00000X , with the licence number:  003715-1 , 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: 7483317 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P2640809 . This is a "OXFORD PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0114716 . This is a "GHI PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: AZ00898 . This is a "MDNY PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2269089 . This is a "UNITED HC PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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