Provider Demographics
NPI:1811211121
Name:SHOBOWALE, STELLA
Entity Type:Individual
Prefix:
First Name:STELLA
Middle Name:
Last Name:SHOBOWALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 BEACH CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1919
Mailing Address - Country:US
Mailing Address - Phone:718-471-5978
Mailing Address - Fax:718-471-5978
Practice Address - Street 1:2929 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1919
Practice Address - Country:US
Practice Address - Phone:718-471-5978
Practice Address - Fax:718-471-5978
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY535900-1163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice