Provider Demographics
NPI:1932818077
Name:ISOM, SHONTA L (CENA)
Entity Type:Individual
Prefix:
First Name:SHONTA
Middle Name:L
Last Name:ISOM
Suffix:
Gender:F
Credentials:CENA
Other - Prefix:
Other - First Name:SHONTA
Other - Middle Name:L
Other - Last Name:TRAPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CENA
Mailing Address - Street 1:14929 LINDSAY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-4401
Mailing Address - Country:US
Mailing Address - Phone:248-688-5080
Mailing Address - Fax:313-340-2694
Practice Address - Street 1:14929 LINDSAY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-4401
Practice Address - Country:US
Practice Address - Phone:248-688-5080
Practice Address - Fax:313-340-2694
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230010755210106376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide