Provider Demographics
NPI:1063850691
Name:DAVIS, SHANTELL LASHAWN (CNA)
Entity Type:Individual
Prefix:MS
First Name:SHANTELL
Middle Name:LASHAWN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 YMCA RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-7602
Mailing Address - Country:US
Mailing Address - Phone:803-445-3659
Mailing Address - Fax:
Practice Address - Street 1:325 YMCA RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29073-7602
Practice Address - Country:US
Practice Address - Phone:803-445-3659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC125852E376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEX6726Medicaid