Healthcare Provider Details

I. General information

NPI: 1386179083
Provider Name (Legal Business Name): SHANNON ECCLES DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 OLD SHORT HILLS RD
LIVINGSTON NJ
07039-5672
US

IV. Provider business mailing address

94 OLD SHORT HILLS RD
LIVINGSTON NJ
07039
US

V. Phone/Fax

Practice location:
  • Phone: 973-322-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS018661
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MB10151000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: