Provider Demographics
NPI:1073274098
Name:SPRAGUE, SHANNON TAYLOR
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:TAYLOR
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 ADAIR DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-3610
Mailing Address - Country:US
Mailing Address - Phone:607-422-9040
Mailing Address - Fax:
Practice Address - Street 1:3313 CHILI AVE STE E
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-5300
Practice Address - Country:US
Practice Address - Phone:585-889-3280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-02
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013541111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty