Provider Demographics
NPI:1407567076
Name:SMITH, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SMITH
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 1:1810 W ROCKLAND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-1017
Mailing Address - Country:US
Mailing Address - Phone:267-709-3079
Mailing Address - Fax:
Practice Address - Street 1:1810 W ROCKLAND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-1017
Practice Address - Country:US
Practice Address - Phone:267-709-3079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA69043601376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty