Provider Demographics
NPI:1588129837
Name:BURRELL, SHANTANA
Entity type:Individual
Prefix:
First Name:SHANTANA
Middle Name:
Last Name:BURRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 SW SAN ANTONIO AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-4837
Mailing Address - Country:US
Mailing Address - Phone:954-540-7002
Mailing Address - Fax:
Practice Address - Street 1:2632 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2845
Practice Address - Country:US
Practice Address - Phone:954-540-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator