Provider Demographics
NPI:1881458792
Name:PARKER, SHANTISE
Entity type:Individual
Prefix:
First Name:SHANTISE
Middle Name:
Last Name:PARKER
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 1:1128 N STILES ST # A
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-6122
Mailing Address - Country:US
Mailing Address - Phone:973-901-3640
Mailing Address - Fax:
Practice Address - Street 1:2040 MILLBURN AVE STE 305
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3716
Practice Address - Country:US
Practice Address - Phone:973-901-3640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier