Provider Demographics
NPI:1710565957
Name:WARE, SHASTA CANTINA
Entity Type:Individual
Prefix:
First Name:SHASTA
Middle Name:CANTINA
Last Name:WARE
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 862
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32145-0862
Mailing Address - Country:US
Mailing Address - Phone:904-692-1131
Mailing Address - Fax:904-692-3856
Practice Address - Street 1:303 WARE LANE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:FL
Practice Address - Zip Code:32145-3214
Practice Address - Country:US
Practice Address - Phone:904-692-1131
Practice Address - Fax:904-692-3856
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1977OtherSELFPAY