Provider Demographics
NPI:1437499456
Name:HAGINS, SHANTELL (LPN)
Entity Type:Individual
Prefix:
First Name:SHANTELL
Middle Name:
Last Name:HAGINS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 AVERY ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-1903
Mailing Address - Country:US
Mailing Address - Phone:585-490-8567
Mailing Address - Fax:
Practice Address - Street 1:171 AVERY ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606-1903
Practice Address - Country:US
Practice Address - Phone:585-490-8567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2014-06-17
Deactivation Date:2014-04-21
Deactivation Code:
Reactivation Date:2014-06-17
Provider Licenses
StateLicense IDTaxonomies
NY307362164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse