Provider Demographics
NPI:1811345507
Name:MOULTRIE, SHUNTRELL
Entity type:Individual
Prefix:MS
First Name:SHUNTRELL
Middle Name:
Last Name:MOULTRIE
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 1:1712 14TH WAY SW APT A
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211-5013
Mailing Address - Country:US
Mailing Address - Phone:205-834-6186
Mailing Address - Fax:
Practice Address - Street 1:1712 14TH WAY SW APT A
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-5013
Practice Address - Country:US
Practice Address - Phone:205-834-6186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor