Healthcare Provider Details

I. General information

NPI: 1801008040
Provider Name (Legal Business Name): SHELLY ANN UTER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 STOCKHOLM ST
BROOKLYN NY
11237-4006
US

IV. Provider business mailing address

42 GOSHEN ST
ELMONT NY
11003-5025
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-7272
  • Fax:
Mailing address:
  • Phone: 516-825-4235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF303119
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: