Healthcare Provider Details

I. General information

NPI: 1306706551
Provider Name (Legal Business Name): SHANICE FLETCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2025
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7925 WINCHESTER BLVD
QUEENS VILLAGE NY
11427-2128
US

IV. Provider business mailing address

19615 118TH AVE
SAINT ALBANS NY
11412-3443
US

V. Phone/Fax

Practice location:
  • Phone: 718-264-4050
  • Fax:
Mailing address:
  • Phone: 917-334-9575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number965078
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: