Provider Demographics
NPI:1245470780
Name:GREEN, SHAUNA CAROLE
Entity type:Individual
Prefix:MRS
First Name:SHAUNA
Middle Name:CAROLE
Last Name:GREEN
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 1:13415 134TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-3516
Mailing Address - Country:US
Mailing Address - Phone:347-431-5844
Mailing Address - Fax:
Practice Address - Street 1:122 E 23RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4516
Practice Address - Country:US
Practice Address - Phone:212-979-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291907091174400000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No174400000XOther Service ProvidersSpecialist