Provider Demographics
NPI:1215250279
Name:MARZULLO, SHANNON D (ANP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:D
Last Name:MARZULLO
Suffix:
Gender:F
Credentials:ANP
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Mailing Address - Street 1:3332 WALDEN AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-2400
Mailing Address - Country:US
Mailing Address - Phone:716-849-8750
Mailing Address - Fax:716-849-8757
Practice Address - Street 1:50 LAKEFRONT BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-4345
Practice Address - Country:US
Practice Address - Phone:716-849-8750
Practice Address - Fax:716-849-8757
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305322-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03600295Medicaid
NYJ400091457Medicare PIN