Provider Demographics
NPI:1528834272
Name:SHAGALOVA, ANNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:SHAGALOVA
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 1:4-25 BRENNAN CT
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5630
Mailing Address - Country:US
Mailing Address - Phone:718-938-0658
Mailing Address - Fax:
Practice Address - Street 1:4-25 BRENNAN CT
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-5630
Practice Address - Country:US
Practice Address - Phone:718-938-0658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01477700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist