Provider Demographics
NPI:1578132247
Name:WATT, SHANICE ROSHANNA
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:ROSHANNA
Last Name:WATT
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 1:2627 ALMA CT
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-2701
Mailing Address - Country:US
Mailing Address - Phone:330-774-0783
Mailing Address - Fax:
Practice Address - Street 1:2627 ALMA CT
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-2701
Practice Address - Country:US
Practice Address - Phone:330-774-0783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSY937370374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty