Provider Demographics
NPI:1225558364
Name:ANDERSON, SHANIQUA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:SHANIQUA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2644 CATALPA DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-2007
Mailing Address - Country:US
Mailing Address - Phone:937-367-5193
Mailing Address - Fax:
Practice Address - Street 1:2644 CATALPA DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-2007
Practice Address - Country:US
Practice Address - Phone:937-367-5193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.136108-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty