Provider Demographics
NPI:1558833145
Name:WALKINE, SHANTELL
Entity Type:Individual
Prefix:
First Name:SHANTELL
Middle Name:
Last Name:WALKINE
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 1:1407 GRAND CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-8134
Mailing Address - Country:US
Mailing Address - Phone:772-249-6749
Mailing Address - Fax:
Practice Address - Street 1:1407 GRAND CLUB BLVD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-8134
Practice Address - Country:US
Practice Address - Phone:772-249-6749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025014000Medicaid