Provider Demographics
NPI:1992135842
Name:LEARY, SHANNON (RN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LEARY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 375
Mailing Address - Street 2:
Mailing Address - City:BLOOMING GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:10914-0375
Mailing Address - Country:US
Mailing Address - Phone:845-500-0943
Mailing Address - Fax:845-496-0404
Practice Address - Street 1:9 VICTORIA DRIVE
Practice Address - Street 2:
Practice Address - City:BLOOMING GROVE
Practice Address - State:NY
Practice Address - Zip Code:10914-0375
Practice Address - Country:US
Practice Address - Phone:845-500-0943
Practice Address - Fax:845-496-0404
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY517778-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse