1396006912 NPI number — MS. VERNICA A SHROUDER R.N.

Table of content: MS. VERNICA A SHROUDER R.N. (NPI 1396006912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396006912 NPI number — MS. VERNICA A SHROUDER R.N.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHROUDER
Provider First Name:
VERNICA
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
R.N.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396006912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5637 188TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESH MEADOWS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11365-2230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5637 188TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESH MEADOWS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11365-2230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-357-4650
Provider Business Practice Location Address Fax Number:
718-357-3507
Provider Enumeration Date:
05/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  00000 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0462174 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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