Provider Demographics
NPI:1508445784
Name:HOLIDAY, SHANICE
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:HOLIDAY
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 1:4225 PICCADILLY LN
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29707-1671
Mailing Address - Country:US
Mailing Address - Phone:704-303-4465
Mailing Address - Fax:
Practice Address - Street 1:4225 PICCADILLY LN
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29707-1671
Practice Address - Country:US
Practice Address - Phone:704-303-4465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC1818174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist