Provider Demographics
NPI:1790597565
Name:FORD, SHANTELL J (RMA, CPT)
Entity type:Individual
Prefix:
First Name:SHANTELL
Middle Name:J
Last Name:FORD
Suffix:
Gender:F
Credentials:RMA, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 KNIGHT ST STE 251
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2566
Mailing Address - Country:US
Mailing Address - Phone:318-780-4031
Mailing Address - Fax:
Practice Address - Street 1:3000 KNIGHT ST STE 251
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2566
Practice Address - Country:US
Practice Address - Phone:318-780-4031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA93103022246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty