Provider Demographics
NPI:1952067506
Name:OSBORNE, SHAWANDA
Entity Type:Individual
Prefix:
First Name:SHAWANDA
Middle Name:
Last Name:OSBORNE
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 1:1102 NAMEOKE ST # 2
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4706
Mailing Address - Country:US
Mailing Address - Phone:347-858-3733
Mailing Address - Fax:
Practice Address - Street 1:1102 NAMEOKE ST # 2
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4706
Practice Address - Country:US
Practice Address - Phone:347-858-3733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342927164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse