Provider Demographics
NPI:1295225621
Name:WILLIAMS, SHAUNTAY CLORICE (LVN)
Entity Type:Individual
Prefix:MRS
First Name:SHAUNTAY
Middle Name:CLORICE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 N GRAPE ST
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3079
Mailing Address - Country:US
Mailing Address - Phone:760-975-9939
Mailing Address - Fax:
Practice Address - Street 1:490 N GRAPE ST
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025
Practice Address - Country:US
Practice Address - Phone:760-975-9939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN684306164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse