Basic Information
| Provider Information | |||||||||
| NPI: | 1811911951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHULOF | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | AMY | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 MOUNTAIN LEDGE | ||||||||
| Address2: | |||||||||
| City: | GANSEVOORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128312539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185840355 | ||||||||
| FaxNumber: | 5185837665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 05/15/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | F380785 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02122109 | 05 | NY | MEDICAID |