Healthcare Provider Details

I. General information

NPI: 1740787597
Provider Name (Legal Business Name): SHAHEDAH FLOYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 TABOR AVE
PHILADELPHIA PA
19120-2124
US

IV. Provider business mailing address

5537 CATHARINE ST
PHILADELPHIA PA
19143-2511
US

V. Phone/Fax

Practice location:
  • Phone: 215-245-2131
  • Fax:
Mailing address:
  • Phone: 215-390-3542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN240245
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: