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NPI Code Detail

MEDICARE: MRS. SHANNON KATHLEEN KELLEY PMHNP, LCSW, CASAC

MEDICARE: MRS. SHANNON KATHLEEN KELLEY PMHNP, LCSW, CASAC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker082228-1NY
2163W00000XRegistered Nurse740606NY
3363LP0808XPsychiatric/Mental Health Nurse Practitioner403004NY

General Provider Information

NPI Number : 1902089238
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. SHANNON KATHLEEN KELLEY PMHNP, LCSW, CASAC
Provider Business Mailing Address
First Line : 713 HARRISON ST
Second Line :
City : SYRACUSE
State : NY
Zip : 13210-2305
Country : US
Telephone Number : 315-464-7655
Fax Number :
Provider Business Practice Location Address
First Line : 713 HARRISON ST
Second Line :
City : SYRACUSE
State : NY
Zip : 13210-2305
Country : US
Telephone Number : 315-464-7655
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/10/2007
Last Update Date : 02/25/2021

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