Provider Demographics
NPI:1922583632
Name:HARRIS, SHAVON
Entity Type:Individual
Prefix:
First Name:SHAVON
Middle Name:
Last Name:HARRIS
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 1:1651 KENSINGTON DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-4158
Mailing Address - Country:US
Mailing Address - Phone:937-829-3152
Mailing Address - Fax:
Practice Address - Street 1:1651 KENSINGTON DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-4158
Practice Address - Country:US
Practice Address - Phone:937-829-3152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.154277.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse