Basic Information
| Provider Information | |||||||||
| NPI: | 1932382785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALTODANO | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | POYNER | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 838 E LIBRA PL | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852493641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802905587 | ||||||||
| FaxNumber: | 6233218009 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 W CLARENDON AVE | ||||||||
| Address2: | SUITE 375 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022774161 | ||||||||
| FaxNumber: | 6022773481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2007 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | DA1804 | AZ | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 23 | 05 | AZ | MEDICAID |