Healthcare Provider Details

I. General information

NPI: 1780662965
Provider Name (Legal Business Name): ELAINE J SHABEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 DELANO ST
PULASKI NY
13142-1400
US

IV. Provider business mailing address

61 DELANO ST
PULASKI NY
13142-1400
US

V. Phone/Fax

Practice location:
  • Phone: 315-298-6564
  • Fax: 315-298-7488
Mailing address:
  • Phone: 315-298-6564
  • Fax: 315-298-7488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number334673
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: