Provider Demographics
NPI:1700372505
Name:NESBIT, SHONTA M
Entity Type:Individual
Prefix:
First Name:SHONTA
Middle Name:M
Last Name:NESBIT
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 1:5150 N 99TH AVE APT 3019
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-3028
Mailing Address - Country:US
Mailing Address - Phone:216-338-8039
Mailing Address - Fax:
Practice Address - Street 1:1400 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-5691
Practice Address - Country:US
Practice Address - Phone:602-567-9881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ046603224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant