Provider Demographics
NPI:1770458317
Name:O'NEILL, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:O'NEILL
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 1:315 E 73RD ST APT 12A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-9410
Mailing Address - Country:US
Mailing Address - Phone:631-827-7323
Mailing Address - Fax:
Practice Address - Street 1:1470 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6542
Practice Address - Country:US
Practice Address - Phone:844-632-2623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312554363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health