Provider Demographics
NPI:1801602495
Name:HARMON, SHANTANECE
Entity type:Individual
Prefix:
First Name:SHANTANECE
Middle Name:
Last Name:HARMON
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:PO BOX 2164
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-2164
Mailing Address - Country:US
Mailing Address - Phone:667-305-5312
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 2164
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-2164
Practice Address - Country:US
Practice Address - Phone:667-305-5312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD225000000X, 224P00000X
MDSXOYKTFQGH335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist