Healthcare Provider Details

I. General information

NPI: 1487902029
Provider Name (Legal Business Name): SHANE LAWRENCE GURNEE RN BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WESTFALL RD
ROCHESTER NY
14620-4647
US

IV. Provider business mailing address

100 CARPENTER LN APT 207
PENN YAN NY
14527-8756
US

V. Phone/Fax

Practice location:
  • Phone: 585-753-5178
  • Fax:
Mailing address:
  • Phone: 585-753-5187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number659843-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: