Provider Demographics
NPI:1487902029
Name:GURNEE, SHANE LAWRENCE (RN BSN)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:LAWRENCE
Last Name:GURNEE
Suffix:
Gender:M
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CARPENTER LN APT 207
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-8756
Mailing Address - Country:US
Mailing Address - Phone:585-753-5187
Mailing Address - Fax:
Practice Address - Street 1:111 WESTFALL RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-4647
Practice Address - Country:US
Practice Address - Phone:585-753-5178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY659843-1163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVYT200514960Medicaid