Provider Demographics
NPI:1316426745
Name:VANGURP, SHAYLA ALYSON (ATC)
Entity type:Individual
Prefix:
First Name:SHAYLA
Middle Name:ALYSON
Last Name:VANGURP
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RAYNOR RD
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-1900
Mailing Address - Country:US
Mailing Address - Phone:631-258-2384
Mailing Address - Fax:
Practice Address - Street 1:630 MORICHES MIDDLE ISLAND RD
Practice Address - Street 2:
Practice Address - City:MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11955-1506
Practice Address - Country:US
Practice Address - Phone:631-874-5505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20000335292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer