Provider Demographics
NPI:1740863893
Name:MAMIYE, SHIRLEY RACHEL
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:RACHEL
Last Name:MAMIYE
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 1:608 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:ALLENHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07711-1420
Mailing Address - Country:US
Mailing Address - Phone:718-208-6747
Mailing Address - Fax:
Practice Address - Street 1:608 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:ALLENHURST
Practice Address - State:NJ
Practice Address - Zip Code:07711-1420
Practice Address - Country:US
Practice Address - Phone:718-208-6747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01147000164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse