Provider Demographics
NPI:1386286748
Name:BRANCH, SHANTICE
Entity type:Individual
Prefix:
First Name:SHANTICE
Middle Name:
Last Name:BRANCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 YORK AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5304
Mailing Address - Country:US
Mailing Address - Phone:646-962-2270
Mailing Address - Fax:
Practice Address - Street 1:1315 YORK AVE FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5304
Practice Address - Country:US
Practice Address - Phone:646-962-2270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant