Healthcare Provider Details

I. General information

NPI: 1982660692
Provider Name (Legal Business Name): SHANTI JONES
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62ND MED GROUP 690 BARNES AVE
MCCHORD AFB WA
98438
US

IV. Provider business mailing address

5516 82ND ST SW APT H202
LAKEWOOD WA
98499-2992
US

V. Phone/Fax

Practice location:
  • Phone: 253-982-6330
  • Fax:
Mailing address:
  • Phone: 253-592-2010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number174167
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: