Healthcare Provider Details

I. General information

NPI: 1639509581
Provider Name (Legal Business Name): SHANA MATTHEWS ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34TH STREET AND CIVIC CENTER BOULEVARD
PHILADELPHIA PA
19104-4399
US

IV. Provider business mailing address

700 MONTCLAIR RD NE
PALM BAY FL
32905-5011
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1000
  • Fax:
Mailing address:
  • Phone: 321-795-3763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9282626
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberARNP3822626
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: