Provider Demographics
NPI:1417182726
Name:ANDERSON, SHONTA SHALONDA (LPN)
Entity Type:Individual
Prefix:
First Name:SHONTA
Middle Name:SHALONDA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6817 N 41ST ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2202
Mailing Address - Country:US
Mailing Address - Phone:414-322-9190
Mailing Address - Fax:
Practice Address - Street 1:6817 N 41ST ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2202
Practice Address - Country:US
Practice Address - Phone:414-322-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-17
Last Update Date:2009-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI304283-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse