Provider Demographics
NPI:1821532417
Name:PERSAUD-NIWAZ, SHALANE (FNP)
Entity Type:Individual
Prefix:
First Name:SHALANE
Middle Name:
Last Name:PERSAUD-NIWAZ
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 1:2 FOXMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5230
Mailing Address - Country:US
Mailing Address - Phone:347-730-2381
Mailing Address - Fax:
Practice Address - Street 1:1600 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5208
Practice Address - Country:US
Practice Address - Phone:347-730-2381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-15
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9386679163W00000X
NY341802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse