Basic Information
| Provider Information | |||||||||
| NPI: | 1912177692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHINE | ||||||||
| FirstName: | MELBA | ||||||||
| MiddleName: | LANIECE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 SILVERPINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | AMITYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117012029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317892115 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 263 BLUE POINT AVE | ||||||||
| Address2: | |||||||||
| City: | BLUE POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117151224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314196737 | ||||||||
| FaxNumber: | 6318683498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2008 | ||||||||
| LastUpdateDate: | 11/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 602544 | NY | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 02572796 | 05 | NY | MEDICAID |