Provider Demographics
NPI:1285025965
Name:DESMOULIN, SHANIKA (RN)
Entity Type:Individual
Prefix:
First Name:SHANIKA
Middle Name:
Last Name:DESMOULIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1766 GLEASON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-4628
Mailing Address - Country:US
Mailing Address - Phone:917-651-9240
Mailing Address - Fax:
Practice Address - Street 1:1766 GLEASON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-4628
Practice Address - Country:US
Practice Address - Phone:917-651-9240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-17
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320771164W00000X
NY738515163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse