Basic Information
| Provider Information | |||||||||
| NPI: | 1982157137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DINGLE | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2685 CRESTON AVE | ||||||||
| Address2: | APT 6B | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104683639 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5676 RIVERDALE AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104712100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187965300 | ||||||||
| FaxNumber: | 7185481161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2016 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 163WP0809X | 616798 | NY | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 402317 | 01 | NY | NURSE PRACTITIONER LICENSE | OTHER |