Provider Demographics
NPI:1114501236
Name:DAVIS, SHANTEL R
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:R
Last Name:DAVIS
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 1:11801 MANGO LN
Mailing Address - Street 2:
Mailing Address - City:NORTH POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20878-2233
Mailing Address - Country:US
Mailing Address - Phone:347-385-4407
Mailing Address - Fax:
Practice Address - Street 1:11801 MANGO LN
Practice Address - Street 2:
Practice Address - City:NORTH POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20878-2233
Practice Address - Country:US
Practice Address - Phone:347-385-4407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program