Provider Demographics
NPI:1063903334
Name:REILLY, SHANNON (FNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 COURT ST APT 7C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-3952
Mailing Address - Country:US
Mailing Address - Phone:413-335-0662
Mailing Address - Fax:
Practice Address - Street 1:505 COURT ST APT 7C
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11231-3952
Practice Address - Country:US
Practice Address - Phone:413-335-0662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341797363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily