Healthcare Provider Details

I. General information

NPI: 1942950076
Provider Name (Legal Business Name): SHIRLEY PAOLA VANEGAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 RIVERSIDE DR
MIDDLETOWN NY
10941-4048
US

IV. Provider business mailing address

11 BLUFFS CT
HAMBURG NJ
07419-1525
US

V. Phone/Fax

Practice location:
  • Phone: 845-695-5600
  • Fax:
Mailing address:
  • Phone: 201-259-8336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number009290-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: