Provider Demographics
NPI:1033822895
Name:STOVER, SHABRESHA NICOLE
Entity type:Individual
Prefix:MS
First Name:SHABRESHA
Middle Name:NICOLE
Last Name:STOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHABRESHA
Other - Middle Name:NICOLE
Other - Last Name:STOVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4616 OAKMONT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-3720
Mailing Address - Country:US
Mailing Address - Phone:215-954-8346
Mailing Address - Fax:
Practice Address - Street 1:4616 OAKMONT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-3720
Practice Address - Country:US
Practice Address - Phone:215-954-8346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA66243601376J00000X, 385H00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No385H00000XRespite Care FacilityRespite Care