Provider Demographics
NPI:1184207433
Name:GIPSON, SHANEQWA
Entity Type:Individual
Prefix:
First Name:SHANEQWA
Middle Name:
Last Name:GIPSON
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 1:242 TUTT RD
Mailing Address - Street 2:
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-3137
Mailing Address - Country:US
Mailing Address - Phone:470-246-7654
Mailing Address - Fax:
Practice Address - Street 1:242 TUTT RD
Practice Address - Street 2:
Practice Address - City:CORNELIA
Practice Address - State:GA
Practice Address - Zip Code:30531-3137
Practice Address - Country:US
Practice Address - Phone:470-246-7654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician