Provider Demographics
NPI:1992386973
Name:WOMACK, SHADELL DANAE MARIA III
Entity Type:Individual
Prefix:
First Name:SHADELL
Middle Name:DANAE MARIA
Last Name:WOMACK
Suffix:III
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHADELL
Other - Middle Name:DANAE MARIA
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 N EL DORADO ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1305
Mailing Address - Country:US
Mailing Address - Phone:209-938-0228
Mailing Address - Fax:
Practice Address - Street 1:301 E 13TH ST STE D
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6211
Practice Address - Country:US
Practice Address - Phone:209-386-1096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA717412164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000Other00000000