Healthcare Provider Details

I. General information

NPI: 1417384611
Provider Name (Legal Business Name): JESSICA LEIGH SHAVER RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4184 MILLER ST
WILLIAMSON NY
14589-9713
US

IV. Provider business mailing address

PO BOX 900
WILLIAMSON NY
14589-0900
US

V. Phone/Fax

Practice location:
  • Phone: 315-589-9665
  • Fax: 315-589-8314
Mailing address:
  • Phone: 315-589-9665
  • Fax: 315-589-8314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number562347-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: