Provider Demographics
NPI:1295979995
Name:WHITMORE, SHALONDA (BA)
Entity type:Individual
Prefix:
First Name:SHALONDA
Middle Name:
Last Name:WHITMORE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 W MAGEE RD
Mailing Address - Street 2:#23102
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-4651
Mailing Address - Country:US
Mailing Address - Phone:216-965-6906
Mailing Address - Fax:520-750-0056
Practice Address - Street 1:699 W MAGEE RD
Practice Address - Street 2:#23102
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-4651
Practice Address - Country:US
Practice Address - Phone:216-965-6906
Practice Address - Fax:520-750-0056
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1613394171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1613394OtherDES OLCR