Provider Demographics
NPI:1396393633
Name:SHERIDAN, EMMANUELLE
Entity type:Individual
Prefix:MRS
First Name:EMMANUELLE
Middle Name:
Last Name:SHERIDAN
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 1:102 FOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-1908
Mailing Address - Country:US
Mailing Address - Phone:934-246-1196
Mailing Address - Fax:
Practice Address - Street 1:102 FOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-1908
Practice Address - Country:US
Practice Address - Phone:934-246-1196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6155301163W00000X, 163WA0400X, 163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05Medicaid
NY6155301Medicaid