Provider Demographics
NPI:1710556816
Name:SMALL, SHANIQUA ELIZABETH
Entity Type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:ELIZABETH
Last Name:SMALL
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 1:232 HARPERS FERRY LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-8812
Mailing Address - Country:US
Mailing Address - Phone:843-478-2123
Mailing Address - Fax:
Practice Address - Street 1:232 HARPERS FERRY LN APT A5
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-8812
Practice Address - Country:US
Practice Address - Phone:843-478-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC121242577376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker