Provider Demographics
NPI:1275961773
Name:DAVIS, SHANDA (STNA)
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3389 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-4709
Mailing Address - Country:US
Mailing Address - Phone:216-916-0708
Mailing Address - Fax:
Practice Address - Street 1:3389 W 95TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-4709
Practice Address - Country:US
Practice Address - Phone:216-916-0708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400688571107374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3153073Medicaid