Provider Demographics
NPI:1972828168
Name:PIERCE, SHANTELL LASHAWNA (LPN)
Entity Type:Individual
Prefix:
First Name:SHANTELL
Middle Name:LASHAWNA
Last Name:PIERCE
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 1:3158 SAGEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-7859
Mailing Address - Country:US
Mailing Address - Phone:937-610-8389
Mailing Address - Fax:
Practice Address - Street 1:3158 SAGEBROOK DR
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-7859
Practice Address - Country:US
Practice Address - Phone:937-610-8389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN 137578-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2850955Medicaid