Provider Demographics
NPI:1962828558
Name:KING, SHAWNA (LPN)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:KING
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 1:1380 CLARKSON PARMA TL RD
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-9423
Mailing Address - Country:US
Mailing Address - Phone:585-613-6572
Mailing Address - Fax:
Practice Address - Street 1:1380 CLARKSON PARMA TL RD
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-9423
Practice Address - Country:US
Practice Address - Phone:585-613-6572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310055164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse