Provider Demographics
NPI:1063919611
Name:IVES, SHANNON (CRNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:IVES
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 MAPLE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:PA
Mailing Address - Zip Code:18444-6862
Mailing Address - Country:US
Mailing Address - Phone:570-237-2312
Mailing Address - Fax:
Practice Address - Street 1:228 INDEPENDENCE RD
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-9435
Practice Address - Country:US
Practice Address - Phone:570-426-2830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018102363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology