Provider Demographics
NPI:1538421219
Name:CORDOVA, SHANNON JOAN
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:JOAN
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:JOAN
Other - Last Name:ROONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:102 FAIRHARBOR DR
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3327
Mailing Address - Country:US
Mailing Address - Phone:631-513-8019
Mailing Address - Fax:
Practice Address - Street 1:102 FAIRHARBOR DR
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3327
Practice Address - Country:US
Practice Address - Phone:631-513-8019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2181989174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist