Provider Demographics
NPI:1043699051
Name:GRIFFIN, ILENE SHUMAKER
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:SHUMAKER
Last Name:GRIFFIN
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 1:2930 OAK TREE LN
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-2655
Mailing Address - Country:US
Mailing Address - Phone:863-709-6569
Mailing Address - Fax:
Practice Address - Street 1:2930 OAK TREE LN
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810
Practice Address - Country:US
Practice Address - Phone:863-709-6569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 253Z00000X
FLCNA105452376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide