Healthcare Provider Details

I. General information

NPI: 1912067034
Provider Name (Legal Business Name): SHANNON HEAVEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON OCZKOWSKI RN

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 ELM ST
MANCHESTER NH
03101-1203
US

IV. Provider business mailing address

2 WALL ST STE 300
MANCHESTER NH
03101-1518
US

V. Phone/Fax

Practice location:
  • Phone: 603-668-4111
  • Fax:
Mailing address:
  • Phone: 603-668-4111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number059741-21
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number059741-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: