MEDICARE: MRS. KHADINE KENESHA SHIELDS LPN

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	300077	NY

General Provider Information

NPI Number	:	1982920674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KHADINE KENESHA SHIELDS LPN

Provider Business Mailing Address
First Line	:	161 WOODRUFF AVE
Second Line	:	APT.1A
City	:	BROOKLYN
State	:	NY
Zip	:	11226-1870
Country	:	US
Telephone Number	:	347-240-6232
Fax Number	:

Provider Business Practice Location Address
First Line	:	161 WOODRUFF AVE
Second Line	:	APT.1A
City	:	BROOKLYN
State	:	NY
Zip	:	11226-1870
Country	:	US
Telephone Number	:	347-240-6232
Fax Number	:

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

Provider Enumeration Date	:	04/20/2010
Last Update Date	:	04/20/2010

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