Provider Demographics
NPI:1245795483
Name:GAYLES, SHAWNEKA
Entity Type:Individual
Prefix:
First Name:SHAWNEKA
Middle Name:
Last Name:GAYLES
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 1:638 CREEKPARK CT
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-8084
Mailing Address - Country:US
Mailing Address - Phone:614-286-1941
Mailing Address - Fax:
Practice Address - Street 1:1233 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-1523
Practice Address - Country:US
Practice Address - Phone:614-972-6493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OHRN.454539163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health