Provider Demographics
NPI:1508530197
Name:CAMPBELL, SHANA KAY VENESA
Entity Type:Individual
Prefix:
First Name:SHANA KAY
Middle Name:VENESA
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANA KAY
Other - Middle Name:
Other - Last Name:WITTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3055 WILSON AVE PH
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5104
Mailing Address - Country:US
Mailing Address - Phone:347-882-3069
Mailing Address - Fax:
Practice Address - Street 1:3055 WILSON AVE PH
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5104
Practice Address - Country:US
Practice Address - Phone:347-882-3069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF342481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily