Healthcare Provider Details

I. General information

NPI: 1275727372
Provider Name (Legal Business Name): SHA DAHA HEGGS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W 97TH ST
NEW YORK NY
10025-6450
US

IV. Provider business mailing address

110 W 97TH ST
NEW YORK NY
10025-6450
US

V. Phone/Fax

Practice location:
  • Phone: 212-749-1820
  • Fax: 212-531-4063
Mailing address:
  • Phone: 212-749-1820
  • Fax: 212-531-4063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number285492
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: