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General NPI Number Information
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NPI Number | 1649094665
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Entity Type | Individual
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Provider Name | SHANTAR ORNELLA NICHOLAS I
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Gender | Female
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Dates
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Enumeration Date | 11/15/2024
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Last Update Date | 11/15/2024
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Provider Practice Location Address
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Address Line | 6412 N UNIVERSITY DR STE 117
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City | TAMARAC
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State | FL
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Zip | 33321-4002
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Country | US
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Telephone | 954-991-9359
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Fax |
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Provider Business Mailing Address
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Address Line | 5770 NW 60TH AVE APT E103
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City | TAMARAC
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State | FL
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Zip | 33319-2446
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Country | US
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Telephone | 954-901-9359
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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