Healthcare Provider Details

I. General information

NPI: 1114539269
Provider Name (Legal Business Name): SHANNON MARIE NICOSIA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 WALKER DR STE 314E
STATE COLLEGE PA
16801-7097
US

IV. Provider business mailing address

270 WALKER DR STE 314E
STATE COLLEGE PA
16801-7097
US

V. Phone/Fax

Practice location:
  • Phone: 406-840-0400
  • Fax:
Mailing address:
  • Phone: 406-219-7836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP025407
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number346354
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: