Provider Demographics
NPI:1912177692
Name:SHINE, MELBA LANIECE (RN)
Entity Type:Individual
Prefix:MS
First Name:MELBA
Middle Name:LANIECE
Last Name:SHINE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:19 SILVERPINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2029
Mailing Address - Country:US
Mailing Address - Phone:631-789-2115
Mailing Address - Fax:
Practice Address - Street 1:263 BLUE POINT AVE
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1224
Practice Address - Country:US
Practice Address - Phone:631-419-6737
Practice Address - Fax:631-868-3498
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY602544163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02572796Medicaid