Provider Demographics
NPI:1649798455
Name:DOUGLAS, SHANDEL (APN)
Entity type:Individual
Prefix:
First Name:SHANDEL
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 EDGEWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901
Mailing Address - Country:US
Mailing Address - Phone:973-395-1550
Mailing Address - Fax:973-395-1556
Practice Address - Street 1:310 CENTRAL AVENUE
Practice Address - Street 2:SUITE 102
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018
Practice Address - Country:US
Practice Address - Phone:973-395-1550
Practice Address - Fax:973-395-1556
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00747600363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care