Provider Demographics
NPI:1104193838
Name:SHAKOW, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SHAKOW
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 1:9 QUEVIC DR
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-9023
Mailing Address - Country:US
Mailing Address - Phone:518-581-7303
Mailing Address - Fax:
Practice Address - Street 1:76 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12803-4912
Practice Address - Country:US
Practice Address - Phone:518-783-9048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020906-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist