Healthcare Provider Details

I. General information

NPI: 1801602495
Provider Name (Legal Business Name): SHANTANECE HARMON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 2164
GLEN BURNIE MD
21060-2164
US

IV. Provider business mailing address

PO BOX 2164
GLEN BURNIE MD
21060-2164
US

V. Phone/Fax

Practice location:
  • Phone: 667-305-5312
  • Fax:
Mailing address:
  • Phone: 667-305-5312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberSXOYKTFQGH
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: