Provider Demographics
NPI:1467900233
Name:FORD, SHANISE
Entity Type:Individual
Prefix:
First Name:SHANISE
Middle Name:
Last Name:FORD
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 1:2365 CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4317
Mailing Address - Country:US
Mailing Address - Phone:850-212-3030
Mailing Address - Fax:
Practice Address - Street 1:510 S MARVIN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-2522
Practice Address - Country:US
Practice Address - Phone:850-212-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No372600000XNursing Service Related ProvidersAdult Companion