Basic Information
| Provider Information | |||||||||
| NPI: | 1568003879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | JEAN | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | LEONARD | ||||||||
| OtherFirstName: | SHANNON | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14 WALL ST FL 9 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100052178 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 259 1ST ST | ||||||||
| Address2: | |||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166638312 | ||||||||
| FaxNumber: | 5166636926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2019 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 024197 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.