Provider Demographics
NPI:1588311260
Name:GALLOWAY, SHALETA
Entity type:Individual
Prefix:
First Name:SHALETA
Middle Name:
Last Name:GALLOWAY
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 1:25742 SKYE CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-1661
Mailing Address - Country:US
Mailing Address - Phone:313-455-7745
Mailing Address - Fax:
Practice Address - Street 1:25742 SKYE CT
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-1661
Practice Address - Country:US
Practice Address - Phone:313-455-7745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17353164W00000X
AZ240162164W00000X
MI4703122868164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MINAOtherN/A