Provider Demographics
NPI:1164579165
Name:PARKER, SHAUNIELLE
Entity Type:Individual
Prefix:DR
First Name:SHAUNIELLE
Middle Name:
Last Name:PARKER
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 1:1700 MYRTLE AVE
Mailing Address - Street 2:58
Mailing Address - City:PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07063-1000
Mailing Address - Country:US
Mailing Address - Phone:908-753-6401
Mailing Address - Fax:908-226-6743
Practice Address - Street 1:1700 MYRTLE AVE
Practice Address - Street 2:58
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07063-1000
Practice Address - Country:US
Practice Address - Phone:908-753-6401
Practice Address - Fax:908-226-6743
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ02245500122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0306789Medicaid
GA901080674AMedicaid