Provider Demographics
NPI:1962034744
Name:FOSTER, SHANTELL
Entity Type:Individual
Prefix:
First Name:SHANTELL
Middle Name:
Last Name:FOSTER
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 1:96159 MOUNT ZION LOOP
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-6332
Mailing Address - Country:US
Mailing Address - Phone:904-753-3285
Mailing Address - Fax:904-849-7124
Practice Address - Street 1:96159 MOUNT ZION LOOP
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-6332
Practice Address - Country:US
Practice Address - Phone:904-753-3285
Practice Address - Fax:904-849-7124
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion