Provider Demographics
NPI:1255099537
Name:SHABAZZ, LATEEFAH
Entity type:Individual
Prefix:
First Name:LATEEFAH
Middle Name:
Last Name:SHABAZZ
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 1:64 S GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ALDAN
Mailing Address - State:PA
Mailing Address - Zip Code:19018-4015
Mailing Address - Country:US
Mailing Address - Phone:215-399-6171
Mailing Address - Fax:
Practice Address - Street 1:1118 W ROCKLAND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3434
Practice Address - Country:US
Practice Address - Phone:215-399-6171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA56983601376J00000X, 385H00000X
PA5698301253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No385H00000XRespite Care FacilityRespite Care