Provider Demographics
NPI:1215405808
Name:SHANNON, MIKEKISHA LESHAWN
Entity Type:Individual
Prefix:
First Name:MIKEKISHA
Middle Name:LESHAWN
Last Name:SHANNON
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 1:203 N ST SW APT 306
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20024-3559
Mailing Address - Country:US
Mailing Address - Phone:202-813-7741
Mailing Address - Fax:
Practice Address - Street 1:4017 MINNESOTA AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3541
Practice Address - Country:US
Practice Address - Phone:202-388-9202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14134374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide