Healthcare Provider Details

I. General information

NPI: 1013363365
Provider Name (Legal Business Name): SHERRY SHABAZZ-MUHAMMAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16840 127TH AVE
ROCHDALE VILLAGE NY
11434-3149
US

IV. Provider business mailing address

16840 127TH AVE
ROCHDALE VILLAGE NY
11434-3149
US

V. Phone/Fax

Practice location:
  • Phone: 718-709-6653
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number262089-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: