Healthcare Provider Details

I. General information

NPI: 1467966960
Provider Name (Legal Business Name): SHANAYA RECALDE CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 WILLIAMSON ST
ELIZABETH NJ
07202-3625
US

IV. Provider business mailing address

80 MIDLAND PL
NEWARK NJ
07106-2806
US

V. Phone/Fax

Practice location:
  • Phone: 908-994-5000
  • Fax:
Mailing address:
  • Phone: 973-979-1262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number25ME00062901
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: