Provider Demographics
NPI:1639720865
Name:JOSEPH, SHOUDLIE MANOTTE (SA-C)
Entity Type:Individual
Prefix:
First Name:SHOUDLIE
Middle Name:MANOTTE
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5811 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-3405
Mailing Address - Country:US
Mailing Address - Phone:347-444-0241
Mailing Address - Fax:
Practice Address - Street 1:5811 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-3405
Practice Address - Country:US
Practice Address - Phone:347-444-0241
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
FL19-399246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant