Provider Demographics
NPI:1215363684
Name:DOUGLAS, SHELLENE
Entity Type:Individual
Prefix:
First Name:SHELLENE
Middle Name:
Last Name:DOUGLAS
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 N JAMES ST
Mailing Address - Street 2:9F
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-2459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 N JAMES ST
Practice Address - Street 2:9F
Practice Address - City:PEEKSKILL
Practice Address - State:NY
Practice Address - Zip Code:10566-2459
Practice Address - Country:US
Practice Address - Phone:914-539-0986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10 313966164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse