MEDICARE: SHATEKE BENNETT RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	655087	NY

General Provider Information

NPI Number	:	1043651698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHATEKE BENNETT RN

Provider Business Mailing Address
First Line	:	963 E 77TH ST
Second Line	:	APT 1
City	:	BROOKLYN
State	:	NY
Zip	:	11236-3825
Country	:	US
Telephone Number	:	401-919-4385
Fax Number	:

Provider Business Practice Location Address
First Line	:	963 E 77TH ST
Second Line	:	APT 1
City	:	BROOKLYN
State	:	NY
Zip	:	11236-3825
Country	:	US
Telephone Number	:	401-919-4385
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2013
Last Update Date	:	07/11/2013

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