Provider Demographics
NPI:1740559632
Name:ALI, MEMUNA SHARDOW (RN)
Entity Type:Individual
Prefix:
First Name:MEMUNA
Middle Name:SHARDOW
Last Name:ALI
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 1:320 MORRIS AVE
Mailing Address - Street 2:10H
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-6106
Mailing Address - Country:US
Mailing Address - Phone:347-329-0485
Mailing Address - Fax:
Practice Address - Street 1:13 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6003
Practice Address - Country:US
Practice Address - Phone:516-823-0739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY644943163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY644943OtherRN LICENSE