Provider Demographics
NPI:1174098495
Name:LISTER, SHANELLE (OWNER)
Entity type:Individual
Prefix:MS
First Name:SHANELLE
Middle Name:
Last Name:LISTER
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:SHANELLE
Other - Middle Name:
Other - Last Name:LISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:167 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19023-3824
Mailing Address - Country:US
Mailing Address - Phone:267-330-9871
Mailing Address - Fax:
Practice Address - Street 1:167 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-3824
Practice Address - Country:US
Practice Address - Phone:267-330-9871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-13
Last Update Date:2018-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty