Healthcare Provider Details

I. General information

NPI: 1477225803
Provider Name (Legal Business Name): SHANNON MARIE PHILLIPS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 GENESEE ST
ONEIDA NY
13421-2658
US

IV. Provider business mailing address

100 METROPOLITAN PARK DR STE 100
LIVERPOOL NY
13088-7112
US

V. Phone/Fax

Practice location:
  • Phone: 315-363-8862
  • Fax: 315-363-5477
Mailing address:
  • Phone: 315-870-9370
  • Fax: 315-870-9364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF348042
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: