Provider Demographics
NPI:1679282537
Name:PICCHI, SHANNON M (A-GNP-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:PICCHI
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 E WRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-1111
Mailing Address - Country:US
Mailing Address - Phone:315-651-1069
Mailing Address - Fax:
Practice Address - Street 1:1991 BALSLEY RD
Practice Address - Street 2:
Practice Address - City:SENECA FALLS
Practice Address - State:NY
Practice Address - Zip Code:13148-9797
Practice Address - Country:US
Practice Address - Phone:315-539-9229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311080363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health