Healthcare Provider Details

I. General information

NPI: 1730505025
Provider Name (Legal Business Name): SHANNON MOORE-SHABAZZ DOULA/BIRTH WORKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6313 N FAIRHILL ST
PHILADELPHIA PA
19126-3846
US

IV. Provider business mailing address

PO BOX 28667
PHILADELPHIA PA
19151-0667
US

V. Phone/Fax

Practice location:
  • Phone: 267-471-8648
  • Fax:
Mailing address:
  • Phone: 267-471-8648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1744G0900X
TaxonomyGraphics Designer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: