Provider Demographics
NPI:1982920674
Name:SHIELDS, KHADINE KENESHA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KHADINE
Middle Name:KENESHA
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 WOODRUFF AVE
Mailing Address - Street 2:APT.1A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-1870
Mailing Address - Country:US
Mailing Address - Phone:347-240-6232
Mailing Address - Fax:
Practice Address - Street 1:161 WOODRUFF AVE
Practice Address - Street 2:APT.1A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-1870
Practice Address - Country:US
Practice Address - Phone:347-240-6232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300077164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse