Provider Demographics
NPI:1063023935
Name:GRANT, SHANIKA LANELL
Entity Type:Individual
Prefix:
First Name:SHANIKA
Middle Name:LANELL
Last Name:GRANT
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 1:1828 ESE, TX-323 LOOP SUITE 101, TYLER, TX 75701
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1828 ESE, TX-323 LOOP SUITE 101, TYLER, TX 75701
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2004
Practice Address - Country:US
Practice Address - Phone:903-363-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217806164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse