Healthcare Provider Details

I. General information

NPI: 1396913521
Provider Name (Legal Business Name): SHAUNA GLENN ZEMKEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CANAL ST
FORT PLAIN NY
13339-1153
US

IV. Provider business mailing address

2 CANAL ST
FORT PLAIN NY
13339-1153
US

V. Phone/Fax

Practice location:
  • Phone: 518-993-4743
  • Fax: 518-993-4743
Mailing address:
  • Phone: 518-993-4743
  • Fax: 518-993-4743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAUNA GLENN ZEMKEN
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 518-993-4743