Provider Demographics
NPI:1033467592
Name:SHABAZZ, AMEENAH
Entity Type:Individual
Prefix:MRS
First Name:AMEENAH
Middle Name:
Last Name:SHABAZZ
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 1:310 BLUE LEDGE DR
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-4835
Mailing Address - Country:US
Mailing Address - Phone:518-496-4381
Mailing Address - Fax:
Practice Address - Street 1:310 BLUE LEDGE DR
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-4835
Practice Address - Country:US
Practice Address - Phone:518-496-4381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist