Provider Demographics
NPI:1083458145
Name:PANTRY, SHAQUETTA A (LPN)
Entity type:Individual
Prefix:MRS
First Name:SHAQUETTA
Middle Name:A
Last Name:PANTRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:SHAQUETTA
Other - Middle Name:A
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:12511 149TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-3717
Mailing Address - Country:US
Mailing Address - Phone:631-379-6041
Mailing Address - Fax:
Practice Address - Street 1:12511 149TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-3717
Practice Address - Country:US
Practice Address - Phone:631-379-6041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339939164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse