Provider Demographics
NPI:1073256616
Name:GREEN, SHANNON (HHA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:HHA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MR GREEN
Mailing Address - Street 1:1216 GRAY AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-3959
Mailing Address - Country:US
Mailing Address - Phone:315-864-0416
Mailing Address - Fax:
Practice Address - Street 1:1216 GRAY AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-3959
Practice Address - Country:US
Practice Address - Phone:315-864-0416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2024-12-24
Deactivation Date:2023-01-01
Deactivation Code:
Reactivation Date:2024-12-24
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1073256616Medicaid
NY13502Medicaid