Healthcare Provider Details

I. General information

NPI: 1053208462
Provider Name (Legal Business Name): SHANISE DYANE SIDDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2025
Last Update Date: 06/19/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 NEW SCOTLAND AVE
ALBANY NY
12208-3409
US

IV. Provider business mailing address

75 WILLETT ST APT 1K
ALBANY NY
12210-1016
US

V. Phone/Fax

Practice location:
  • Phone: 518-549-6616
  • Fax:
Mailing address:
  • Phone: 607-267-8911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number710596
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: