Healthcare Provider Details

I. General information

NPI: 1245951490
Provider Name (Legal Business Name): SHARISE SHAJAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 HALF HOLLOW RD
DIX HILLS NY
11746-5859
US

IV. Provider business mailing address

148 PINE ST
NEW HYDE PARK NY
11040-2419
US

V. Phone/Fax

Practice location:
  • Phone: 631-370-1700
  • Fax:
Mailing address:
  • Phone: 516-492-0268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number749860
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: