Provider Demographics
NPI:1114510997
Name:COKE, SHANTELLE LOUISE
Entity Type:Individual
Prefix:
First Name:SHANTELLE
Middle Name:LOUISE
Last Name:COKE
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 1:3694 SUMMERLIN LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1650
Mailing Address - Country:US
Mailing Address - Phone:813-445-9509
Mailing Address - Fax:
Practice Address - Street 1:3694 SUMMERLIN LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1650
Practice Address - Country:US
Practice Address - Phone:813-445-9509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11011221363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily