Healthcare Provider Details

I. General information

NPI: 1679115588
Provider Name (Legal Business Name): MRS. SHEA LYNN BEACHNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 INTREPID LN
SYRACUSE NY
13205-2548
US

IV. Provider business mailing address

6373 LAKESHORE RD
CICERO NY
13039-8827
US

V. Phone/Fax

Practice location:
  • Phone: 315-437-4689
  • Fax:
Mailing address:
  • Phone: 315-247-3076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number812557981
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number785742971
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: