Provider Demographics
NPI:1174996334
Name:GLYNN, SHANA MARIE (MS, RPA-C, RD, CDN)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:MARIE
Last Name:GLYNN
Suffix:
Gender:F
Credentials:MS, RPA-C, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 JAN WAY
Mailing Address - Street 2:
Mailing Address - City:CALVERTON
Mailing Address - State:NY
Mailing Address - Zip Code:11933-3005
Mailing Address - Country:US
Mailing Address - Phone:631-508-5400
Mailing Address - Fax:631-910-2322
Practice Address - Street 1:525 JAN WAY
Practice Address - Street 2:
Practice Address - City:CALVERTON
Practice Address - State:NY
Practice Address - Zip Code:11933
Practice Address - Country:US
Practice Address - Phone:631-508-5400
Practice Address - Fax:631-910-2322
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007626133V00000X
NY019490363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant