Provider Demographics
NPI:1013656073
Name:PELTON, SHAMIA
Entity type:Individual
Prefix:
First Name:SHAMIA
Middle Name:
Last Name:PELTON
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 1:3171 S 129TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-3205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10605 E 66TH ST APT 224
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-2641
Practice Address - Country:US
Practice Address - Phone:991-622-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-28
Last Update Date:2022-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK200437164W00000X
CA699148164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse