MEDICARE: SHANI MANDISA KETEMA DOULA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374J00000X	Doula		NJ

General Provider Information

NPI Number	:	1104414069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANI MANDISA KETEMA DOULA

Provider Business Mailing Address
First Line	:	45 KENMORE AVE APT 3
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07106-1048
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	45 KENMORE AVE APT 3
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07106-1048
Country	:	US
Telephone Number	:	973-953-8152
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2021
Last Update Date	:	01/06/2021

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