Provider Demographics
NPI:1619390911
Name:GRADY, SHACOYA LATRECE (LPN)
Entity Type:Individual
Prefix:
First Name:SHACOYA
Middle Name:LATRECE
Last Name:GRADY
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 1:1202 S NEBRASKA ST
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71601-6197
Mailing Address - Country:US
Mailing Address - Phone:870-592-3641
Mailing Address - Fax:
Practice Address - Street 1:3450 W 34TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-5508
Practice Address - Country:US
Practice Address - Phone:870-534-7392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL52687164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse