Provider Demographics
NPI:1659587566
Name:BROWN, SHANTE MONIQUE (LPN)
Entity Type:Individual
Prefix:
First Name:SHANTE
Middle Name:MONIQUE
Last Name:BROWN
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 1:441 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1121
Mailing Address - Country:US
Mailing Address - Phone:419-612-3458
Mailing Address - Fax:
Practice Address - Street 1:441 DAVIS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1121
Practice Address - Country:US
Practice Address - Phone:419-612-3458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 112635164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2497534Medicaid