Provider Demographics
NPI:1164653622
Name:MEYERS, SHANNON NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:MEYERS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:NICOLE
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2209 GENESEE STREET
Mailing Address - Street 2:BUSINESS OFFICE ROOM 310
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501
Mailing Address - Country:US
Mailing Address - Phone:315-801-3282
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:4752 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-6205
Practice Address - Country:US
Practice Address - Phone:315-275-3046
Practice Address - Fax:315-275-3048
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335917363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03207650Medicaid
NYJ400014031Medicare PIN