Provider Demographics
NPI:1629787916
Name:DENISOFF, SHANNON MARLENE (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARLENE
Last Name:DENISOFF
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARLENE
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGPCNP-BC
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:
Practice Address - Street 1:100 BROAD ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4349
Practice Address - Country:US
Practice Address - Phone:518-792-2223
Practice Address - Fax:518-792-8231
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311144363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07551980Medicaid