Provider Demographics
NPI:1760112742
Name:BAILEY, SHANTIDRA
Entity Type:Individual
Prefix:
First Name:SHANTIDRA
Middle Name:
Last Name:BAILEY
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 1:1160 E NORTHERN PKWY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-1933
Mailing Address - Country:US
Mailing Address - Phone:443-374-8188
Mailing Address - Fax:
Practice Address - Street 1:1160 E NORTHERN PKWY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-1933
Practice Address - Country:US
Practice Address - Phone:443-374-8188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24R-115246RP1900X
MDA00109435376K00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No376K00000XNursing Service Related ProvidersNurse's Aide