Provider Demographics
NPI:1043800212
Name:LIDDELL, SHAREKA
Entity Type:Individual
Prefix:
First Name:SHAREKA
Middle Name:
Last Name:LIDDELL
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 1:78 BOXWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-6070
Mailing Address - Country:US
Mailing Address - Phone:414-499-7378
Mailing Address - Fax:
Practice Address - Street 1:78 BOXWOOD LN
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-6070
Practice Address - Country:US
Practice Address - Phone:414-499-7378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide