Provider Demographics
NPI:1396410429
Name:COLES, SHAQUANTA TANIQUE
Entity Type:Individual
Prefix:
First Name:SHAQUANTA
Middle Name:TANIQUE
Last Name:COLES
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 1:602 SUNRISE FIVE WAY APT H
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-3794
Mailing Address - Country:US
Mailing Address - Phone:804-401-6774
Mailing Address - Fax:
Practice Address - Street 1:602 SUNRISE FIVE WAY APT H
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-3794
Practice Address - Country:US
Practice Address - Phone:804-401-6774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver