Provider Demographics
NPI:1598153819
Name:MATLOCK, COCOANISHA SHEANTA
Entity Type:Individual
Prefix:
First Name:COCOANISHA
Middle Name:SHEANTA
Last Name:MATLOCK
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 1:3100 STARLITE DR NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-1618
Mailing Address - Country:US
Mailing Address - Phone:216-371-9858
Mailing Address - Fax:
Practice Address - Street 1:3100 STARLITE DR NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-1618
Practice Address - Country:US
Practice Address - Phone:216-371-9858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH501134600606376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3146170Medicaid