Provider Demographics
NPI:1053744425
Name:O'BRIEN, SHANNON NICOLE (PA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:NICOLE
Other - Last Name:WANICHKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1034 GROVE STREET
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-373-3530
Mailing Address - Fax:814-333-1757
Practice Address - Street 1:640 ALDEN ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2348
Practice Address - Country:US
Practice Address - Phone:814-373-5255
Practice Address - Fax:814-373-5259
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003787363A00000X
IL085004752363AM0700X
PAMA058204363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant