Provider Demographics
NPI:1790030864
Name:SHIMONOV, SHUSHANO (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SHUSHANO
Middle Name:
Last Name:SHIMONOV
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 1:6259 108TH ST APT 3L
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1307
Mailing Address - Country:US
Mailing Address - Phone:718-275-9718
Mailing Address - Fax:
Practice Address - Street 1:6259 108TH ST APT 3L
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1307
Practice Address - Country:US
Practice Address - Phone:718-275-9718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269184164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse