Healthcare Provider Details

I. General information

NPI: 1194187542
Provider Name (Legal Business Name): SHANNA NEVELEV MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNA KOFMAN

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 WAYNE AVE FL 8
BRONX NY
10467-2552
US

IV. Provider business mailing address

3411 WAYNE AVE FL 8
BRONX NY
10467-2552
US

V. Phone/Fax

Practice location:
  • Phone: 718-741-2507
  • Fax:
Mailing address:
  • Phone: 718-741-2507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number297352
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: