Provider Demographics
NPI:1427787043
Name:LAGERAAEN, SHANNON S
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:S
Last Name:LAGERAAEN
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 1:13 GROVER LN
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-3014
Mailing Address - Country:US
Mailing Address - Phone:631-848-1403
Mailing Address - Fax:
Practice Address - Street 1:13 GROVER LN
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-3014
Practice Address - Country:US
Practice Address - Phone:631-848-1403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer