Healthcare Provider Details

I. General information

NPI: 1992391320
Provider Name (Legal Business Name): TRACY SHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2020
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 MONTGOMERY ST FL 603
JERSEY CITY NJ
07302-3726
US

IV. Provider business mailing address

75 MONTGOMERY ST FL 603
JERSEY CITY NJ
07302-3726
US

V. Phone/Fax

Practice location:
  • Phone: 201-433-1955
  • Fax:
Mailing address:
  • Phone: 201-433-1955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number345858
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: