MEDICARE: SHANE RODNEY

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	164W00000X	Licensed Practical Nurse	313527	NY

General Provider Information

NPI Number	:	1588075642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE RODNEY

Provider Business Mailing Address
First Line	:	3622 CLARENDON RD
Second Line	:	APT 1
City	:	BROOKLYN
State	:	NY
Zip	:	11203-5104
Country	:	US
Telephone Number	:	347-607-7208
Fax Number	:

Provider Business Practice Location Address
First Line	:	3622 CLARENDON RD
Second Line	:	APT 1
City	:	BROOKLYN
State	:	NY
Zip	:	11203-5104
Country	:	US
Telephone Number	:	347-607-7208
Fax Number	:

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

Provider Enumeration Date	:	05/12/2014
Last Update Date	:	05/12/2014

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