Provider Demographics
NPI:1154058709
Name:SLACK, SHERINE M (RN)
Entity type:Individual
Prefix:
First Name:SHERINE
Middle Name:M
Last Name:SLACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22115 HEMPSTEAD AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2106
Mailing Address - Country:US
Mailing Address - Phone:716-418-3030
Mailing Address - Fax:
Practice Address - Street 1:22115 HEMPSTEAD AVE APT 2D
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-2106
Practice Address - Country:US
Practice Address - Phone:716-418-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY776567-01163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice