Healthcare Provider Details

I. General information

NPI: 1437667185
Provider Name (Legal Business Name): SHANNON HOLLIDAY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2067 MASSACHUSETTS AVE
CAMBRIDGE MA
02140-1340
US

IV. Provider business mailing address

PO BOX 358
MEXICO NY
13114-0358
US

V. Phone/Fax

Practice location:
  • Phone: 617-575-5570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number661312
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: