Healthcare Provider Details

I. General information

NPI: 1760904577
Provider Name (Legal Business Name): SHENEQUA THOMAS NURSE PRACTICIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GREENWOOD PL
VALLEY STREAM NY
11581-1810
US

IV. Provider business mailing address

20 GREENWOOD PL
VALLEY STREAM NY
11581-1810
US

V. Phone/Fax

Practice location:
  • Phone: 718-978-4999
  • Fax:
Mailing address:
  • Phone: 929-402-9311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number358351
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: