Provider Demographics
NPI:1366004319
Name:DAVIS, SHIANDRA KEYATA
Entity Type:Individual
Prefix:
First Name:SHIANDRA
Middle Name:KEYATA
Last Name:DAVIS
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 1:4201 S IRBY ST LOT 14
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-5311
Mailing Address - Country:US
Mailing Address - Phone:843-373-8284
Mailing Address - Fax:
Practice Address - Street 1:4201 S IRBY ST LOT 14
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-5311
Practice Address - Country:US
Practice Address - Phone:843-373-8284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-30
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC01151991Medicaid