Provider Demographics
NPI:1700893914
Name:BLUME-KESSELRING, SHANNON (NP)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:BLUME-KESSELRING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 GENESEE STREET
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413
Mailing Address - Country:US
Mailing Address - Phone:315-732-7909
Mailing Address - Fax:315-793-9307
Practice Address - Street 1:86 GENESEE STREET
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413
Practice Address - Country:US
Practice Address - Phone:315-732-7909
Practice Address - Fax:315-793-9307
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4918541163WP0200X
NYF333382363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02254557Medicaid
NY02996981Medicaid
NY02873201Medicaid