Provider Demographics
NPI:1174864813
Name:SHELLS, LATOSHIA
Entity Type:Individual
Prefix:
First Name:LATOSHIA
Middle Name:
Last Name:SHELLS
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 1:3006 WALSH ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-2538
Mailing Address - Country:US
Mailing Address - Phone:336-497-1098
Mailing Address - Fax:
Practice Address - Street 1:3006 WALSH ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-2538
Practice Address - Country:US
Practice Address - Phone:336-497-1098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC201309300687251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health