Provider Demographics
NPI:1215281977
Name:PASSALACQUA, SHANNON LYNN (DC)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LYNN
Last Name:PASSALACQUA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-2246
Mailing Address - Country:US
Mailing Address - Phone:315-521-5665
Mailing Address - Fax:
Practice Address - Street 1:514 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-2246
Practice Address - Country:US
Practice Address - Phone:315-521-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-02
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012248111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor