Provider Demographics
NPI:1043818966
Name:BROWN, SHAKERIA C
Entity Type:Individual
Prefix:
First Name:SHAKERIA
Middle Name:C
Last Name:BROWN
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 1:567 MILLVILLE AVE APT 3-10
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-2337
Mailing Address - Country:US
Mailing Address - Phone:203-415-8608
Mailing Address - Fax:
Practice Address - Street 1:567 MILLVILLE AVE APT 3-10
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-2337
Practice Address - Country:US
Practice Address - Phone:203-415-8608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.009248363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12.009248Medicaid