Provider Demographics
NPI:1285995118
Name:SMALLS, SHAWN JERMAINE (NURSE)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:JERMAINE
Last Name:SMALLS
Suffix:
Gender:M
Credentials:NURSE
Other - Prefix:MR
Other - First Name:SHAWN
Other - Middle Name:
Other - Last Name:SMALLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NURSE
Mailing Address - Street 1:2250 HICKORY RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1047
Mailing Address - Country:US
Mailing Address - Phone:610-888-0588
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD
Practice Address - Street 2:SUITE 240
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1047
Practice Address - Country:US
Practice Address - Phone:302-998-0469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL2-0010853164W00000X
PAPN278828164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE164W00000XOtherINDIVIDUAL PROVIDER
PA164W00000XOtherINDIVIDUAL PROVIDER
MD164W00000XOtherINDIVIDUAL PROVIDER