Provider Demographics
NPI:1255935078
Name:SHADDAD, KYYANIA (CERTIFIED DOULA)
Entity type:Individual
Prefix:MS
First Name:KYYANIA
Middle Name:
Last Name:SHADDAD
Suffix:
Gender:F
Credentials:CERTIFIED DOULA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-2114
Mailing Address - Country:US
Mailing Address - Phone:973-856-4499
Mailing Address - Fax:
Practice Address - Street 1:97 S 10TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-2114
Practice Address - Country:US
Practice Address - Phone:973-856-4499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty