Provider Demographics
NPI:1871726612
Name:ANDERSEN, SHANNON M (BSN, FNP-BC, AOCNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:BSN, FNP-BC, AOCNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:KORTEKAAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN, OCN
Mailing Address - Street 1:296 DEKALB AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-3733
Mailing Address - Country:US
Mailing Address - Phone:425-418-5342
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:FLOOR 4, SUITE 4
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY540332163W00000X
NY335789363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse