Healthcare Provider Details

I. General information

NPI: 1184171639
Provider Name (Legal Business Name): SUZETT SIMONE SHAW APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/14/2025
Certification Date: 09/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 UNIVERSITY PLZ STE 204
HACKENSACK NJ
07601-6211
US

IV. Provider business mailing address

2 UNIVERSITY PLZ STE 204
HACKENSACK NJ
07601-6211
US

V. Phone/Fax

Practice location:
  • Phone: 551-295-8223
  • Fax:
Mailing address:
  • Phone: 551-295-8223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number26NJ00645900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ00645900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0760081
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: