Provider Demographics
NPI:1871604306
Name:OLIVERIO, SHANNON L (ANP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:OLIVERIO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3024
Mailing Address - Country:US
Mailing Address - Phone:585-760-1260
Mailing Address - Fax:585-271-0002
Practice Address - Street 1:150 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3024
Practice Address - Country:US
Practice Address - Phone:585-760-1264
Practice Address - Fax:585-271-0002
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304207363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02886051Medicaid
RB4766 (70008A GRP)Medicare PIN
NY02886051Medicaid