Healthcare Provider Details

I. General information

NPI: 1336643618
Provider Name (Legal Business Name): KATHLEEN SHANLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3732 CARMAN RD
SCHENECTADY NY
12303-5422
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD STE 203
LATHAM NY
12110-2461
US

V. Phone/Fax

Practice location:
  • Phone: 518-356-4132
  • Fax:
Mailing address:
  • Phone: 518-782-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number311492
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: