Provider Demographics
NPI:1184158453
Name:DILLARD, SHANTINEE YVONNE
Entity type:Individual
Prefix:
First Name:SHANTINEE
Middle Name:YVONNE
Last Name:DILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANTINEE
Other - Middle Name:YVONNE
Other - Last Name:TERRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5224 28TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1960
Mailing Address - Country:US
Mailing Address - Phone:651-592-4333
Mailing Address - Fax:
Practice Address - Street 1:7625 METRO BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55439-3053
Practice Address - Country:US
Practice Address - Phone:612-821-2189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker