Healthcare Provider Details

I. General information

NPI: 1801657309
Provider Name (Legal Business Name): SHANNON VAVALLE ATC, CES, OTC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4433 VESTAL PKWY E
VESTAL NY
13850-3556
US

IV. Provider business mailing address

4433 VESTAL PKWY E
VESTAL NY
13850-3556
US

V. Phone/Fax

Practice location:
  • Phone: 607-771-2220
  • Fax: 607-251-2635
Mailing address:
  • Phone: 607-771-2220
  • Fax: 607-251-2635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number020802088
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: