Provider Demographics
NPI:1700216751
Name:THEOPHILUS, SHERVONE (RN)
Entity Type:Individual
Prefix:
First Name:SHERVONE
Middle Name:
Last Name:THEOPHILUS
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 1:33 ROOSEVELT DR APT 319
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1670
Mailing Address - Country:US
Mailing Address - Phone:321-439-8426
Mailing Address - Fax:
Practice Address - Street 1:85 BARTLETT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-4429
Practice Address - Country:US
Practice Address - Phone:718-782-1538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY671217163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health