Provider Demographics
NPI:1992578165
Name:SMALLS, SHANIA SHERRELL
Entity type:Individual
Prefix:
First Name:SHANIA
Middle Name:SHERRELL
Last Name:SMALLS
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 1:253 MAYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-8892
Mailing Address - Country:US
Mailing Address - Phone:843-670-0410
Mailing Address - Fax:
Practice Address - Street 1:9201 E MOUNTAIN VIEW RD STE 220
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5172
Practice Address - Country:US
Practice Address - Phone:480-298-7571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28083363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology