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NPI Code Detail

MEDICARE: RAVEN-JADE HARLEQUINN SHADDOWS

MEDICARE: RAVEN-JADE HARLEQUINN SHADDOWS
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
1171M00000XCase Manager/Care Coordinator

General Provider Information

NPI Number : 1336987684
Entity Type Code : Individual
Provider Name (Legal Business Name) : RAVEN-JADE HARLEQUINN SHADDOWS
Provider Business Mailing Address
First Line : 324 COUNTY ROUTE 51 BLDG 1
Second Line :
City : MALONE
State : NY
Zip : 12953-4502
Country : US
Telephone Number : 518-483-1251
Fax Number : 518-483-2242
Provider Business Practice Location Address
First Line : 650 STATE ST
Second Line :
City : WATERTOWN
State : NY
Zip : 13601-2839
Country : US
Telephone Number : 315-755-1251
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/19/2024
Last Update Date : 06/11/2026

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Directions to “ RAVEN-JADE HARLEQUINN SHADDOWS ” Practice Location

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