Provider Demographics
NPI:1841835691
Name:GREGORY, SHANEKA (NP)
Entity type:Individual
Prefix:
First Name:SHANEKA
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9821 AVENUE K
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4407
Mailing Address - Country:US
Mailing Address - Phone:347-721-5751
Mailing Address - Fax:
Practice Address - Street 1:6740 4TH AVE FL 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-5350
Practice Address - Country:US
Practice Address - Phone:929-455-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF309067-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner