Provider Demographics
NPI:1386357689
Name:DAGUILH, SHANTELLE (DNP)
Entity type:Individual
Prefix:
First Name:SHANTELLE
Middle Name:
Last Name:DAGUILH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 85TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4328
Mailing Address - Country:US
Mailing Address - Phone:201-679-0089
Mailing Address - Fax:
Practice Address - Street 1:473 RIVER RD STE 114
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1145
Practice Address - Country:US
Practice Address - Phone:201-679-0089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01414300363L00000X
NYF350427363L00000X
NY350427363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner