Provider Demographics
NPI:1972880359
Name:SHIELDS, MATILDA H (DPH)
Entity type:Individual
Prefix:
First Name:MATILDA
Middle Name:H
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5136 MORNINGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-4878
Mailing Address - Country:US
Mailing Address - Phone:615-941-4196
Mailing Address - Fax:
Practice Address - Street 1:518 DONELSON PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37214-3729
Practice Address - Country:US
Practice Address - Phone:615-883-5108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8158183500000X
MSE-8285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist