Healthcare Provider Details

I. General information

NPI: 1275108078
Provider Name (Legal Business Name): MISS SHANLAY ETIENNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 05/24/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COASTAL NEPHROLOGY & HYPERTENSION CENTER, P.A. 641 UNIVERSITY BLVD SUITE 211
JUPITER FL
33458
US

IV. Provider business mailing address

641 UNIVERSITY BLVD STE 211
JUPITER FL
33458-2794
US

V. Phone/Fax

Practice location:
  • Phone: 561-253-8121
  • Fax: 561-253-8021
Mailing address:
  • Phone: 561-253-8121
  • Fax: 561-253-8021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11011180
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: