Provider Demographics
NPI:1063966323
Name:WANLESS, SHANNON (FNP- BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WANLESS
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 1:46 NEWMAN SPRINGS RD E
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46 NEWMAN SPRINGS RD E
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1530
Practice Address - Country:US
Practice Address - Phone:732-264-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR16099000163WE0003X
NJ26NJ00661400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency