Provider Demographics
NPI:1609397884
Name:SHINE, SHOSHANA (FNP)
Entity Type:Individual
Prefix:
First Name:SHOSHANA
Middle Name:
Last Name:SHINE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 S BELGRADE RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-3252
Mailing Address - Country:US
Mailing Address - Phone:718-954-1248
Mailing Address - Fax:
Practice Address - Street 1:907 S BELGRADE RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902
Practice Address - Country:US
Practice Address - Phone:718-954-1248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY675313-1163W00000X
MDR224972163W00000X, 363LF0000X
NYF341377-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse