=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174837868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISS SHANA ELAYNE STAGE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2010
-----------------------------------------------------
Last Update Date | 08/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 RAPP RD
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12203-4491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-867-3061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 MORNING GLORY WAY
-----------------------------------------------------
City | SCHENECTADY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12306-3338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-355-0509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 007599-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------