Provider Demographics
NPI:1134588759
Name:ETSHALOM, SHIRA (NP-C)
Entity type:Individual
Prefix:
First Name:SHIRA
Middle Name:
Last Name:ETSHALOM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:YONAH
Other - Middle Name:
Other - Last Name:ETSHALOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:178 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-4165
Mailing Address - Country:US
Mailing Address - Phone:845-471-1530
Mailing Address - Fax:
Practice Address - Street 1:178 CHURCH ST
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-4165
Practice Address - Country:US
Practice Address - Phone:845-471-1530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-11
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340580363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily