Provider Demographics
NPI:1104364686
Name:CHURCH, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CHURCH
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:PO BOX 14890
Mailing Address - Street 2:ST. PETER'S HEALTH PARTNERS PAYER CREDENTIALING
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:5 PALISADES DRIVE SUITE 200
Practice Address - Street 2:ST. PETER'S INTERNAL MEDICINE
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-6433
Practice Address - Country:US
Practice Address - Phone:518-438-0019
Practice Address - Fax:518-438-0299
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY611605163W00000X
NYF341370-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse