Basic Information
| Provider Information | |||||||||
| NPI: | 1487727228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW-QUINN | ||||||||
| FirstName: | LEEANNE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 JORDAN LN | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061091278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602360253 | ||||||||
| FaxNumber: | 8602630262 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HYDE AVE STE 109 | ||||||||
| Address2: | |||||||||
| City: | VERNON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060664503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604540303 | ||||||||
| FaxNumber: | 8608754242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 06/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 002642 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 004026424 | 05 | CT | MEDICAID |