Provider Demographics
NPI:1699179507
Name:NANKISSORE, LUCILLE SHAMA
Entity Type:Individual
Prefix:MRS
First Name:LUCILLE
Middle Name:SHAMA
Last Name:NANKISSORE
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 1:2941 DANA LN
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-5016
Mailing Address - Country:US
Mailing Address - Phone:407-201-4095
Mailing Address - Fax:
Practice Address - Street 1:2941 DANA LN
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5016
Practice Address - Country:US
Practice Address - Phone:407-201-4095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12570310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL12570Medicaid