Provider Demographics
NPI:1104296987
Name:MACVICAR, SHANNYN
Entity type:Individual
Prefix:
First Name:SHANNYN
Middle Name:
Last Name:MACVICAR
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 1:99 FARMERS INN RD
Mailing Address - Street 2:
Mailing Address - City:HOOSICK FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12090-4112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 FARMERS INN RD
Practice Address - Street 2:
Practice Address - City:HOOSICK FALLS
Practice Address - State:NY
Practice Address - Zip Code:12090-4112
Practice Address - Country:US
Practice Address - Phone:518-530-7702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY636835163WH0200X
VT0110287163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health