Provider Demographics
NPI:1619495371
Name:PALMER, SHELIA ANN
Entity Type:Individual
Prefix:
First Name:SHELIA
Middle Name:ANN
Last Name:PALMER
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 1:20228 DALFSEN AVE
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-2934
Mailing Address - Country:US
Mailing Address - Phone:310-384-4907
Mailing Address - Fax:
Practice Address - Street 1:1775 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-1674
Practice Address - Country:US
Practice Address - Phone:310-384-4907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$Medicaid