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NPI Code Detail

MEDICARE: SHADE ELIZABETH DE JESUS

MEDICARE: SHADE ELIZABETH DE JESUS
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
1106S00000XBehavior TechnicianD222785895450FL

General Provider Information

NPI Number : 1861153447
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHADE ELIZABETH DE JESUS
Provider Business Mailing Address
First Line : 4200 INVERRARY BLVD APT 3807
Second Line :
City : LAUDERHILL
State : FL
Zip : 33319-4136
Country : US
Telephone Number : 917-691-6891
Fax Number :
Provider Business Practice Location Address
First Line : 6750 N ANDREWS AVE STE 200
Second Line :
City : FT LAUDERDALE
State : FL
Zip : 33309-2180
Country : US
Telephone Number : 954-758-8748
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/05/2022
Last Update Date : 01/05/2022

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Directions to “ SHADE ELIZABETH DE JESUS ” Practice Location

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