Provider Demographics
NPI:1245462928
Name:CODY, SHANELL
Entity type:Individual
Prefix:
First Name:SHANELL
Middle Name:
Last Name:CODY
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:PO BOX 81
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33882-0081
Mailing Address - Country:US
Mailing Address - Phone:863-210-4292
Mailing Address - Fax:
Practice Address - Street 1:4130 COUNTRY CLUB RD S
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-8228
Practice Address - Country:US
Practice Address - Phone:863-210-4292
Practice Address - Fax:863-875-5348
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA87627376K00000X
FL693195296374U00000X
FL693195298376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002344700Medicaid
FL693195296Medicaid
FL693195296Medicaid