Healthcare Provider Details

I. General information

NPI: 1255904751
Provider Name (Legal Business Name): SHANTEL ECCLESTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12103 234TH ST
ROSEDALE NY
11422-1026
US

IV. Provider business mailing address

12103 234TH ST
ROSEDALE NY
11422-1026
US

V. Phone/Fax

Practice location:
  • Phone: 347-232-0792
  • Fax:
Mailing address:
  • Phone: 347-232-0792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number679343
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number350494
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: