Provider Demographics
NPI:1225758162
Name:MAITLAND, SHANAE MONIQUE
Entity Type:Individual
Prefix:
First Name:SHANAE
Middle Name:MONIQUE
Last Name:MAITLAND
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 1:116 BROADWAY STE 3
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2797
Mailing Address - Country:US
Mailing Address - Phone:631-640-2088
Mailing Address - Fax:
Practice Address - Street 1:619 BROADWAY UNIT 4
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2149
Practice Address - Country:US
Practice Address - Phone:347-206-0733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program