Healthcare Provider Details

I. General information

NPI: 1225493679
Provider Name (Legal Business Name): SHANNON SITCHENKO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2015
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 66TH RD
FOREST HILLS NY
11375-2029
US

IV. Provider business mailing address

755 NORTH AVE NE APT 1424
ATLANTA GA
30306-4410
US

V. Phone/Fax

Practice location:
  • Phone: 718-830-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number677943
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3400388
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: