Provider Demographics
NPI:1285099341
Name:CONNOLLY, SHANNON (DC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CONNOLLY
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:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-0545
Mailing Address - Country:US
Mailing Address - Phone:301-741-8173
Mailing Address - Fax:862-300-3340
Practice Address - Street 1:222 BROADWAY FL 19
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2550
Practice Address - Country:US
Practice Address - Phone:347-989-2865
Practice Address - Fax:862-300-3340
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012764-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor