Provider Demographics
NPI:1558044230
Name:WALDEN, SHONTAE (LPN)
Entity Type:Individual
Prefix:
First Name:SHONTAE
Middle Name:
Last Name:WALDEN
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 1:3711 NW 21ST ST APT 307
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33311-3158
Mailing Address - Country:US
Mailing Address - Phone:305-834-5390
Mailing Address - Fax:
Practice Address - Street 1:3711 NW 21ST ST APT 307
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33311-3158
Practice Address - Country:US
Practice Address - Phone:305-834-5390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 225CA2500X, 246RP1900X, 251K00000X, 174N00000X, 374J00000X, 385H00000X, 385HR2055X, 385HR2060X, 385HR2065X
FL5250597164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No171400000XOther Service ProvidersHealth & Wellness Coach
No225CA2500XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Supplier
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No251K00000XAgenciesPublic Health or Welfare
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child