Provider Demographics
NPI:1073235578
Name:THOMPSON-WHITE, SHANNAKAY JUDDIAN
Entity Type:Individual
Prefix:
First Name:SHANNAKAY
Middle Name:JUDDIAN
Last Name:THOMPSON-WHITE
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 1:1205 SHELMIRE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2726
Mailing Address - Country:US
Mailing Address - Phone:856-392-9900
Mailing Address - Fax:
Practice Address - Street 1:1205 SHELMIRE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2726
Practice Address - Country:US
Practice Address - Phone:856-392-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR19666000163W00000X
PARN695502163W00000X
NJ26NJ01374700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse