Provider Demographics
NPI:1407534985
Name:SHATTUCK, DANIELLE NICOLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:SHATTUCK
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 1:260 E MIDDLE COUNTRY RD STE 208
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2925
Mailing Address - Country:US
Mailing Address - Phone:631-863-3223
Mailing Address - Fax:631-863-3334
Practice Address - Street 1:260 E MIDDLE COUNTRY RD STE 208
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2925
Practice Address - Country:US
Practice Address - Phone:631-863-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311302-01363LA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health