Provider Demographics
NPI:1780093476
Name:ISHAM, SHONDA I
Entity type:Individual
Prefix:MS
First Name:SHONDA
Middle Name:
Last Name:ISHAM
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHONDA
Other - Middle Name:
Other - Last Name:ISHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2733 LAFEUILLE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-7627
Mailing Address - Country:US
Mailing Address - Phone:513-873-3751
Mailing Address - Fax:
Practice Address - Street 1:2733 LAFEUILLE AVE APT 1
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-7627
Practice Address - Country:US
Practice Address - Phone:513-873-3751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH050532167171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor