Provider Demographics
NPI:1225498322
Name:MCCRAE, SHANEQUA
Entity Type:Individual
Prefix:
First Name:SHANEQUA
Middle Name:
Last Name:MCCRAE
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 1:523 KINGSTON AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225
Mailing Address - Country:US
Mailing Address - Phone:646-641-2029
Mailing Address - Fax:
Practice Address - Street 1:523 KINGSTON AVE
Practice Address - Street 2:APT 2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-4664
Practice Address - Country:US
Practice Address - Phone:646-641-2029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322184164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse