Provider Demographics
NPI:1598450157
Name:MAGAMBO, SHANEISA
Entity Type:Individual
Prefix:
First Name:SHANEISA
Middle Name:
Last Name:MAGAMBO
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 1:930 MANTON WAY
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15210-1744
Mailing Address - Country:US
Mailing Address - Phone:814-691-1618
Mailing Address - Fax:412-207-3551
Practice Address - Street 1:930 MANTON WAY
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15210-1744
Practice Address - Country:US
Practice Address - Phone:814-691-1618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAG9T8F4K3251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health