Provider Demographics
NPI:1699326967
Name:O'MALLEY, SHANNON MARIE (DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HUNTERS DR S
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-8667
Mailing Address - Country:US
Mailing Address - Phone:585-955-3588
Mailing Address - Fax:
Practice Address - Street 1:700 ISLAND COTTAGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-2312
Practice Address - Country:US
Practice Address - Phone:585-368-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044676225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist