Healthcare Provider Details

I. General information

NPI: 1194527655
Provider Name (Legal Business Name): TUNESIA SHAVON JETER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLARKSON AVE
BROOKLYN NY
11203-2054
US

IV. Provider business mailing address

14850 BROOKVILLE BLVD
ROSEDALE NY
11422-3275
US

V. Phone/Fax

Practice location:
  • Phone: 718-245-4620
  • Fax:
Mailing address:
  • Phone: 646-246-3432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF356058
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: