MEDICARE: SHANTELL SMALL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376J00000X	Homemaker

General Provider Information

NPI Number	:	1831717339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTELL SMALL

Provider Business Mailing Address
First Line	:	1355 TAOS DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63138-2317
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1355 TAOS DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63138-2317
Country	:	US
Telephone Number	:	314-489-4935
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2020
Last Update Date	:	07/10/2020

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Directions to “ SHANTELL SMALL ” Practice Location

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