Provider Demographics
NPI:1003290289
Name:MACKEY, SHANTEL
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:
Last Name:MACKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 E PROSPECT AVE
Mailing Address - Street 2:APT 6C
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2366
Mailing Address - Country:US
Mailing Address - Phone:914-563-6041
Mailing Address - Fax:
Practice Address - Street 1:231 E PROSPECT AVE
Practice Address - Street 2:APT 6C
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2366
Practice Address - Country:US
Practice Address - Phone:914-563-6041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2231925174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist