Provider Demographics
NPI:1710390885
Name:KELLY, SHANICE (LPN)
Entity type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:KELLY
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 1:471 VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-4813
Mailing Address - Country:US
Mailing Address - Phone:347-636-1169
Mailing Address - Fax:
Practice Address - Street 1:471 VERMONT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-4813
Practice Address - Country:US
Practice Address - Phone:347-636-1169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3180261164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse