Provider Demographics
NPI:1104646504
Name:SHINE, BRENNA (NP-C)
Entity type:Individual
Prefix:MRS
First Name:BRENNA
Middle Name:
Last Name:SHINE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2329 LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3021
Mailing Address - Country:US
Mailing Address - Phone:516-578-9429
Mailing Address - Fax:
Practice Address - Street 1:1 DAKOTA DR STE 302
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1136
Practice Address - Country:US
Practice Address - Phone:516-622-6145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF31082401363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health