Provider Demographics
NPI:1447753694
Name:MORRIS, SHAKERA ANN
Entity Type:Individual
Prefix:
First Name:SHAKERA
Middle Name:ANN
Last Name:MORRIS
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 1:1166 SE PURITAN LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3226
Mailing Address - Country:US
Mailing Address - Phone:772-634-2451
Mailing Address - Fax:
Practice Address - Street 1:905 NE PRIMA VISTA BLVD STE A
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-2360
Practice Address - Country:US
Practice Address - Phone:772-634-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019104900Medicaid