Provider Demographics
NPI:1790216802
Name:WILLIAMS, SHANEEN (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:SHANEEN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 CYPRESS WOODS DR APT 159
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-3779
Mailing Address - Country:US
Mailing Address - Phone:321-662-7301
Mailing Address - Fax:
Practice Address - Street 1:3412 ALOMA AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3900
Practice Address - Country:US
Practice Address - Phone:321-662-7301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL12618211744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management