Provider Demographics
NPI:1528562105
Name:MITCHELL, SHANNIQUA (FNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNIQUA
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 BENSON ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVERSTRAW
Mailing Address - State:NY
Mailing Address - Zip Code:10993-1303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94 BENSON ST
Practice Address - Street 2:
Practice Address - City:WEST HAVERSTRAW
Practice Address - State:NY
Practice Address - Zip Code:10993-1303
Practice Address - Country:US
Practice Address - Phone:845-274-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY357874363LF0000X
NY627210163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY627210OtherLICENSE