Healthcare Provider Details

I. General information

NPI: 1619889979
Provider Name (Legal Business Name): SHATAVIA BROOKS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 DEWEY AVE
ROCHESTER NY
14616-3741
US

IV. Provider business mailing address

189 LAKE AVE APT 8
ROCHESTER NY
14608-1205
US

V. Phone/Fax

Practice location:
  • Phone: 585-865-1550
  • Fax:
Mailing address:
  • Phone: 716-910-1660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number339378
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: