Provider Demographics
NPI:1407399744
Name:BALLARD, SHAMANI (APN)
Entity Type:Individual
Prefix:
First Name:SHAMANI
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WHITE HORSE PIKE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1938
Mailing Address - Country:US
Mailing Address - Phone:856-547-0539
Mailing Address - Fax:856-796-9183
Practice Address - Street 1:210 W ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:HADDON HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08035-1715
Practice Address - Country:US
Practice Address - Phone:856-547-0539
Practice Address - Fax:856-796-9183
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ00000000363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner