Provider Demographics
NPI:1821690264
Name:BOCOOK, SHANTEL ELISE
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:ELISE
Last Name:BOCOOK
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 1:747 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-5238
Mailing Address - Country:US
Mailing Address - Phone:740-221-7319
Mailing Address - Fax:
Practice Address - Street 1:747 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-5238
Practice Address - Country:US
Practice Address - Phone:740-221-7319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6002331374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6002331Medicaid