Provider Demographics
NPI:1558715300
Name:BUCKHANNAN, VELTRICE SHANTESSA (LPN)
Entity Type:Individual
Prefix:MS
First Name:VELTRICE
Middle Name:SHANTESSA
Last Name:BUCKHANNAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 CHURCHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-9404
Mailing Address - Country:US
Mailing Address - Phone:786-277-2402
Mailing Address - Fax:
Practice Address - Street 1:904 CHURCHFIELD DR
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-9404
Practice Address - Country:US
Practice Address - Phone:786-277-2402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN084284164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse