Provider Demographics
NPI:1548025976
Name:BOSTON, SHAVON
Entity type:Individual
Prefix:
First Name:SHAVON
Middle Name:
Last Name:BOSTON
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 1:21535 MURDOCK AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2639
Mailing Address - Country:US
Mailing Address - Phone:718-915-0280
Mailing Address - Fax:
Practice Address - Street 1:21535 MURDOCK AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-2639
Practice Address - Country:US
Practice Address - Phone:718-915-0280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1230976731171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach