Healthcare Provider Details

I. General information

NPI: 1588150593
Provider Name (Legal Business Name): SHANIQUA NICOLE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 NORTH RD
POUGHKEEPSIE NY
12601-1154
US

IV. Provider business mailing address

19 BRADHURST AVE STE 3100N
HAWTHORNE NY
10532-2140
US

V. Phone/Fax

Practice location:
  • Phone: 845-483-5000
  • Fax:
Mailing address:
  • Phone: 914-909-9018
  • Fax: 914-909-9028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number636904
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number402439
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: