MEDICARE: SHERINE M SLACK RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	776567-01	NY

General Provider Information

NPI Number	:	1154058709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERINE M SLACK RN

Provider Business Mailing Address
First Line	:	22115 HEMPSTEAD AVE APT 2D
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11429-2106
Country	:	US
Telephone Number	:	716-418-3030
Fax Number	:

Provider Business Practice Location Address
First Line	:	22115 HEMPSTEAD AVE APT 2D
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11429-2106
Country	:	US
Telephone Number	:	716-418-3030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2022
Last Update Date	:	08/03/2022

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