Provider Demographics
NPI:1053950238
Name:WALLER, SHAKIRA
Entity type:Individual
Prefix:
First Name:SHAKIRA
Middle Name:
Last Name:WALLER
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 1:2612 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-5202
Mailing Address - Country:US
Mailing Address - Phone:215-385-6270
Mailing Address - Fax:
Practice Address - Street 1:2929 ARCH STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-872-0138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-05
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA10012712376K00000X
PA251E00000X, 253Z00000X, 332U00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No376K00000XNursing Service Related ProvidersNurse's Aide
No253Z00000XAgenciesIn Home Supportive Care
No332U00000XSuppliersHome Delivered Meals
No372600000XNursing Service Related ProvidersAdult Companion