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General NPI Number Information
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NPI Number | 1700828340
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Entity Type | Individual
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Provider Name | SHANNAN MARIE MAXEY-RICOY RPA-C
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Gender | Female
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Dates
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Enumeration Date | 06/11/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 221 BROADWAY SUITE 207
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City | AMITYVILLE
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State | NY
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Zip | 11701-2780
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Country | US
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Telephone | 631-598-0009
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Fax | 631-598-0099
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Provider Business Mailing Address
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Address Line | 99 KENTUCKY ST
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City | LONG BEACH
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State | NY
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Zip | 11561-1229
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Country | US
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Telephone | 516-902-8389
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Fax | 516-897-6458
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 009533
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License Number State | NY
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