Healthcare Provider Details

I. General information

NPI: 1225847957
Provider Name (Legal Business Name): SHAYNA MARIE KSANZNAK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 INDEPENDENCE RD
EAST STROUDSBURG PA
18301-7916
US

IV. Provider business mailing address

505 INDEPENDENCE RD
EAST STROUDSBURG PA
18301-7916
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-8900
  • Fax:
Mailing address:
  • Phone: 610-402-8900
  • Fax: 610-402-5623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP031030
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP031030
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: