Healthcare Provider Details

I. General information

NPI: 1447845607
Provider Name (Legal Business Name): SHANNON MARIE ROSS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 FRANKLIN TPKE
WALDWICK NJ
07463-1847
US

IV. Provider business mailing address

48 3RD ST
PEQUANNOCK NJ
07440-1219
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-3603
  • Fax:
Mailing address:
  • Phone: 973-349-4009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number26NR18744700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ01164000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: