Provider Demographics
NPI:1295076164
Name:LOCK, SHANELLE ELIZA
Entity type:Individual
Prefix:
First Name:SHANELLE
Middle Name:ELIZA
Last Name:LOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANELLE
Other - Middle Name:
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2330 BAYLIS AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2807
Mailing Address - Country:US
Mailing Address - Phone:646-857-9221
Mailing Address - Fax:
Practice Address - Street 1:7000 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1022
Practice Address - Country:US
Practice Address - Phone:718-495-7802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-02
Last Update Date:2013-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY778861174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist