Healthcare Provider Details

I. General information

NPI: 1477149250
Provider Name (Legal Business Name): CAMILLE PHEONA SHAKO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7404 5TH AVE
BROOKLYN NY
11209-2704
US

IV. Provider business mailing address

472 GRAMATAN AVE APT I3
MOUNT VERNON NY
10552-2900
US

V. Phone/Fax

Practice location:
  • Phone: 718-439-5111
  • Fax:
Mailing address:
  • Phone: 914-610-0561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number342467
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number342467
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: