Provider Demographics
NPI:1053829705
Name:MACHALIWA, JACQUELINE SHANDELLE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SHANDELLE
Last Name:MACHALIWA
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 1:17401 COMMERCE PARK BLVD STE 1000
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3501
Mailing Address - Country:US
Mailing Address - Phone:813-900-1118
Mailing Address - Fax:
Practice Address - Street 1:17401 COMMERCE PARK BLVD STE 1000
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3501
Practice Address - Country:US
Practice Address - Phone:813-900-1118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL823901801Medicaid
FL823901801Medicaid