Healthcare Provider Details

I. General information

NPI: 1689145260
Provider Name (Legal Business Name): SHELLY-ANN LENORE JOSEPH CERT. HAIR LOSS SPT.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2018
Last Update Date: 12/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 ROCKAWAY AVE
BROOKLYN NY
11212-5635
US

IV. Provider business mailing address

664 RIVERDALE AVE
BROOKLYN NY
11207-5852
US

V. Phone/Fax

Practice location:
  • Phone: 347-452-2732
  • Fax:
Mailing address:
  • Phone: 347-542-2732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: