Provider Demographics
NPI:1811198658
Name:BOOTH, SHIMECA N (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SHIMECA
Middle Name:N
Last Name:BOOTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2644 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3642
Mailing Address - Country:US
Mailing Address - Phone:937-559-2985
Mailing Address - Fax:937-262-7635
Practice Address - Street 1:2644 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3642
Practice Address - Country:US
Practice Address - Phone:937-559-2985
Practice Address - Fax:937-262-7635
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.114708-MED164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2548603Medicare UPIN