Healthcare Provider Details

I. General information

NPI: 1407712128
Provider Name (Legal Business Name): SHEA REILLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2025
Last Update Date: 12/26/2025
Certification Date: 12/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N JAMES ST
ROME NY
13440-2844
US

IV. Provider business mailing address

9700 BEARTOWN RD N
AVA NY
13303-1914
US

V. Phone/Fax

Practice location:
  • Phone: 315-338-7000
  • Fax:
Mailing address:
  • Phone: 315-225-5986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: