Healthcare Provider Details

I. General information

NPI: 1063986578
Provider Name (Legal Business Name): WALIYYAH SHAHIDAH MUHSIN RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 BAINBRIDGE ST
PHILADELPHIA PA
19147-1810
US

IV. Provider business mailing address

1348 BAINBRIDGE ST
PHILADELPHIA PA
19147-1810
US

V. Phone/Fax

Practice location:
  • Phone: 215-563-0658
  • Fax: 215-923-0286
Mailing address:
  • Phone: 215-563-0658
  • Fax: 215-923-0286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number636031
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number636031
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: