Provider Demographics
NPI:1982157137
Name:DINGLE, SHANNON R (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:DINGLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4867 BROADWAY, #839
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034
Mailing Address - Country:US
Mailing Address - Phone:646-830-4735
Mailing Address - Fax:
Practice Address - Street 1:4867 BROADWAY, #839
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034
Practice Address - Country:US
Practice Address - Phone:646-830-4735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-24
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402317363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY402317OtherNURSE PRACTITIONER LICENSE