Provider Demographics
NPI:1447845607
Name:ROSS, SHANNON MARIE (FNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:ROSS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PEQUANNOCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07440-1219
Mailing Address - Country:US
Mailing Address - Phone:973-349-4009
Mailing Address - Fax:
Practice Address - Street 1:140 FRANKLIN TPKE
Practice Address - Street 2:
Practice Address - City:WALDWICK
Practice Address - State:NJ
Practice Address - Zip Code:07463-1847
Practice Address - Country:US
Practice Address - Phone:201-447-3603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR18744700163WE0003X
NJ26NJ01164000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency