Provider Demographics
NPI:1477164390
Name:WILLIAMS, SHANQUETRIS (CNA)
Entity Type:Individual
Prefix:
First Name:SHANQUETRIS
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 CRABAPPLE PL
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-5575
Mailing Address - Country:US
Mailing Address - Phone:478-365-4458
Mailing Address - Fax:
Practice Address - Street 1:613 CRABAPPLE PL
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-5575
Practice Address - Country:US
Practice Address - Phone:478-365-4458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0030041243376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide