Provider Demographics
NPI:1689266900
Name:COGLE, SHONTAE
Entity Type:Individual
Prefix:
First Name:SHONTAE
Middle Name:
Last Name:COGLE
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:PO BOX 3043
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3043
Mailing Address - Country:US
Mailing Address - Phone:706-495-5364
Mailing Address - Fax:706-814-6777
Practice Address - Street 1:114 SHARTOM DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-4748
Practice Address - Country:US
Practice Address - Phone:706-814-6777
Practice Address - Fax:706-814-6777
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No172A00000XOther Service ProvidersDriver
No251300000XAgenciesLocal Education Agency (LEA)
No332U00000XSuppliersHome Delivered Meals