Healthcare Provider Details

I. General information

NPI: 1568081248
Provider Name (Legal Business Name): SHANNON CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 DAVIS AVE
NEPTUNE NJ
07753-4488
US

IV. Provider business mailing address

570 LEXINGTON AVE FL 9
NEW YORK NY
10022-6710
US

V. Phone/Fax

Practice location:
  • Phone: 732-775-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00841700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: