Provider Demographics
NPI:1114620341
Name:ROBERTSON, SHANA DANIELLE (RN)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:DANIELLE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6990 ANGIE DR
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-8966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:848 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2816
Practice Address - Country:US
Practice Address - Phone:901-287-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS910621163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care