Provider Demographics
NPI:1861768764
Name:KAMM, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KAMM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 BIRD AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-1078
Mailing Address - Country:US
Mailing Address - Phone:716-536-0832
Mailing Address - Fax:
Practice Address - Street 1:574 MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-1751
Practice Address - Country:US
Practice Address - Phone:716-608-3110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY48007452133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered