Provider Demographics
NPI:1366731101
Name:BODEN, SHAYNA B (LMT)
Entity type:Individual
Prefix:MISS
First Name:SHAYNA
Middle Name:B
Last Name:BODEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 GREEN ST STE 107
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3336
Mailing Address - Country:US
Mailing Address - Phone:631-692-4476
Mailing Address - Fax:
Practice Address - Street 1:23 GREEN ST STE 107
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3336
Practice Address - Country:US
Practice Address - Phone:631-692-4476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27 024642174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist