Provider Demographics
NPI:1417820887
Name:HULLABY, SHANTAYA BRIANA
Entity type:Individual
Prefix:
First Name:SHANTAYA
Middle Name:BRIANA
Last Name:HULLABY
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 1:4620 W BURGESS LN
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-1922
Mailing Address - Country:US
Mailing Address - Phone:602-472-9815
Mailing Address - Fax:
Practice Address - Street 1:4620 W BURGESS LN
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-1922
Practice Address - Country:US
Practice Address - Phone:602-472-9815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-24
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant