Provider Demographics
NPI:1932382785
Name:BALTODANO, SHELLEY POYNER (AUD)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:POYNER
Last Name:BALTODANO
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:LYNN
Other - Last Name:POYNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:4838 E BASELINE RD STE 126
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4673
Mailing Address - Country:US
Mailing Address - Phone:480-290-5587
Mailing Address - Fax:623-806-8685
Practice Address - Street 1:4838 E BASELINE RD STE 126
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4673
Practice Address - Country:US
Practice Address - Phone:480-265-8067
Practice Address - Fax:623-806-8685
Is Sole Proprietor?:No
Enumeration Date:2007-12-14
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA1804231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ301835Medicaid