Provider Demographics
NPI:1720340607
Name:BLACKMAN, SHERNICE JENELL
Entity Type:Individual
Prefix:MS
First Name:SHERNICE
Middle Name:JENELL
Last Name:BLACKMAN
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 1:11321 200TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2526
Mailing Address - Country:US
Mailing Address - Phone:718-464-1809
Mailing Address - Fax:
Practice Address - Street 1:2 ROOSEVELT AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3064
Practice Address - Country:US
Practice Address - Phone:516-496-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist