Provider Demographics
NPI:1396013785
Name:SHINE, QUIVONNA (LPN)
Entity Type:Individual
Prefix:
First Name:QUIVONNA
Middle Name:
Last Name:SHINE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 STOCKBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1707
Mailing Address - Country:US
Mailing Address - Phone:716-578-0038
Mailing Address - Fax:
Practice Address - Street 1:400 FOREST AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-1207
Practice Address - Country:US
Practice Address - Phone:716-885-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299417164W00000X
NY738847163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse