Basic Information
| Provider Information | |||||||||
| NPI: | 1760557425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANAHAN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | R.D., C.D.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 216 GLEN SUMMER RD | ||||||||
| Address2: | |||||||||
| City: | HOLBROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117415025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314726717 | ||||||||
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| Practice Location | |||||||||
| Address1: | 45 RESEARCH WAY | ||||||||
| Address2: | |||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117336401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319412000 | ||||||||
| FaxNumber: | 6319412010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 003715-1 | NY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 7483317 | 01 | NY | AETNA PROVIDER NUMBER | OTHER | P2640809 | 01 | NY | OXFORD PROVIDER NUMBER | OTHER | 0114716 | 01 | NY | GHI PROVIDER NUMBER | OTHER | AZ00898 | 01 | NY | MDNY PROVIDER NUMBER | OTHER | 2269089 | 01 | NY | UNITED HC PROVIDER NUMBER | OTHER |