Basic Information
| Provider Information | |||||||||
| NPI: | 1194153601 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHATLOVA | ||||||||
| FirstName: | JACQUELENE | ||||||||
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| OtherLastName: | BRONFELD | ||||||||
| OtherFirstName: | JACQUELENE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11781 LEE JACKSON MEMORIAL HWY | ||||||||
| Address2: | STE 550 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220333309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5717775164 | ||||||||
| FaxNumber: | 7038902650 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 DEKALB AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112015425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182508259 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2013 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 93704 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 571828 | NY | Y | Nursing Service Providers | Registered Nurse |
No ID Information.