Provider Demographics
NPI:1306190764
Name:GATES, SHONDALIN A
Entity Type:Individual
Prefix:MRS
First Name:SHONDALIN
Middle Name:A
Last Name:GATES
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 1:30277 COPPERWOODS DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-5124
Mailing Address - Country:US
Mailing Address - Phone:574-343-2057
Mailing Address - Fax:
Practice Address - Street 1:30277 COPPERWOODS DR
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-5124
Practice Address - Country:US
Practice Address - Phone:574-343-2057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8919032164343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)