Provider Demographics
NPI:1518518745
Name:SHALLOWHORN, JONTIA
Entity Type:Individual
Prefix:
First Name:JONTIA
Middle Name:
Last Name:SHALLOWHORN
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 1:26929 NUCIA DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4983
Mailing Address - Country:US
Mailing Address - Phone:661-492-4743
Mailing Address - Fax:
Practice Address - Street 1:26929 NUCIA DR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4983
Practice Address - Country:US
Practice Address - Phone:661-492-4743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-29
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB9256240171000000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB9256240OtherCALIFORNIA DRIVER'S LICENSE