Provider Demographics
NPI:1598359523
Name:LIDDELL, SHANTA (NURSE AIDE)
Entity Type:Individual
Prefix:
First Name:SHANTA
Middle Name:
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:NURSE AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10016 OAK RUN DR APT H
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-0139
Mailing Address - Country:US
Mailing Address - Phone:937-361-1438
Mailing Address - Fax:
Practice Address - Street 1:10016 OAK RUN DR APT H
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-0139
Practice Address - Country:US
Practice Address - Phone:937-361-1438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-20
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC541922376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide