Provider Demographics
NPI:1871116939
Name:MCBAIN, SHONNELL DANA
Entity type:Individual
Prefix:
First Name:SHONNELL
Middle Name:DANA
Last Name:MCBAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5018 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-5936
Mailing Address - Country:US
Mailing Address - Phone:917-930-4331
Mailing Address - Fax:
Practice Address - Street 1:410 LAKEVILLE RD STE 200
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1103
Practice Address - Country:US
Practice Address - Phone:516-708-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-24
Last Update Date:2025-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY333777390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program