Basic Information
Provider Information | |||||||||
NPI: | 1598039810 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CUNNINGHAM | ||||||||
FirstName: | SHONDA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CPNP-AC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | YOCHAM | ||||||||
OtherFirstName: | SHONDA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CPNP-AC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 733784 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753733784 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6828851855 | ||||||||
FaxNumber: | 6828851396 | ||||||||
Practice Location | |||||||||
Address1: | 801 7TH AVE | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761042733 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6828857942 | ||||||||
FaxNumber: | 6828857956 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2012 | ||||||||
LastUpdateDate: | 05/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 693700 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0222X | 693700 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care |
No ID Information.