Provider Demographics
NPI:1467947226
Name:COX, DEDRA SHANTAY
Entity Type:Individual
Prefix:
First Name:DEDRA
Middle Name:SHANTAY
Last Name:COX
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 1:15 WESTLAND PINE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-9517
Mailing Address - Country:US
Mailing Address - Phone:803-394-2228
Mailing Address - Fax:
Practice Address - Street 1:15 WESTLAND PINE CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-9517
Practice Address - Country:US
Practice Address - Phone:803-394-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2018-56113-55006372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No372600000XNursing Service Related ProvidersAdult Companion