Provider Demographics
NPI:1194153601
Name:SHATLOVA, JACQUELENE
Entity type:Individual
Prefix:
First Name:JACQUELENE
Middle Name:
Last Name:SHATLOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELENE
Other - Middle Name:
Other - Last Name:BRONFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11781 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:STE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3309
Mailing Address - Country:US
Mailing Address - Phone:571-777-5164
Mailing Address - Fax:703-890-2650
Practice Address - Street 1:121 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5425
Practice Address - Country:US
Practice Address - Phone:718-250-8259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-18
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY571828367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400108109Medicare PIN