Provider Demographics
NPI:1699797183
Name:KENNEDY, SHANNON M (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:43 NEW SCOTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3412
Mailing Address - Country:US
Mailing Address - Phone:518-262-5196
Mailing Address - Fax:518-262-6472
Practice Address - Street 1:47 NEW SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-5196
Practice Address - Fax:518-262-6472
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY430254363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner