Healthcare Provider Details

I. General information

NPI: 1700893914
Provider Name (Legal Business Name): SHANNON BLUME-KESSELRING NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 11/02/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 GENESEE STREET
NEW HARTFORD NY
13413
US

IV. Provider business mailing address

86 GENESEE STREET
NEW HARTFORD NY
13413
US

V. Phone/Fax

Practice location:
  • Phone: 315-732-7909
  • Fax: 315-793-9307
Mailing address:
  • Phone: 315-732-7909
  • Fax: 315-793-9307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number4918541
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF333382
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: