Provider Demographics
NPI:1104631753
Name:SHANLEY, JENNIFER (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHANLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 FOWLER AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2910
Mailing Address - Country:US
Mailing Address - Phone:607-821-8926
Mailing Address - Fax:
Practice Address - Street 1:425 ROBINSON ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13904-1735
Practice Address - Country:US
Practice Address - Phone:607-773-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY551187163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health