MEDICARE: NICOLE KRISTEN SHANKS

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1194334714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE KRISTEN SHANKS

Provider Business Mailing Address
First Line	:	25 ROUTE 376
Second Line	:
City	:	HOPEWELL JUNCTION
State	:	NY
Zip	:	12533-7211
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 ROUTE 376
Second Line	:
City	:	HOPEWELL JUNCTION
State	:	NY
Zip	:	12533-7211
Country	:	US
Telephone Number	:	845-897-1788
Fax Number	:

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

Provider Enumeration Date	:	07/29/2020
Last Update Date	:	07/29/2020

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