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General NPI Number Information
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NPI Number | 1104193838
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Entity Type | Individual
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Provider Name | NICOLE SHAKOW
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Gender | Female
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Dates
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Enumeration Date | 11/23/2011
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Last Update Date | 11/23/2011
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Provider Practice Location Address
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Address Line | 76 HARRISON AVE
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City | SOUTH GLENS FALLS
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State | NY
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Zip | 12803-4912
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Country | US
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Telephone | 518-783-9048
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Fax |
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Provider Business Mailing Address
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Address Line | 9 QUEVIC DR
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City | SARATOGA SPRINGS
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State | NY
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Zip | 12866-9023
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Country | US
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Telephone | 518-581-7303
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 020906-1
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License Number State | NY
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