Provider Demographics
NPI:1740772532
Name:FELICIANO, SHELLY ANN
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:FELICIANO
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 1:1020 CALHOUN AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-1911
Mailing Address - Country:US
Mailing Address - Phone:718-769-2698
Mailing Address - Fax:718-292-0208
Practice Address - Street 1:329 E 149TH ST FL 4
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5626
Practice Address - Country:US
Practice Address - Phone:347-928-2084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT189119420OtherLICENSE