Provider Demographics
NPI:1548639487
Name:CREEDON, SHANNON (CPNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CREEDON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 BRIGGSBORO LN
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3805
Mailing Address - Country:US
Mailing Address - Phone:315-507-1878
Mailing Address - Fax:
Practice Address - Street 1:3488 DEPEW AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-7015
Practice Address - Country:US
Practice Address - Phone:941-764-7923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY686564163W00000X
FLAPRN11014376363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty