Provider Demographics
NPI:1295090306
Name:VANTERPOOL, SHANTELL P (MSED)
Entity type:Individual
Prefix:MISS
First Name:SHANTELL
Middle Name:P
Last Name:VANTERPOOL
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 5TH AVE APT 10E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3124
Mailing Address - Country:US
Mailing Address - Phone:917-399-3154
Mailing Address - Fax:
Practice Address - Street 1:1309 5TH AVE APT 10E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-3124
Practice Address - Country:US
Practice Address - Phone:917-399-3154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XMedicaid