Provider Demographics
NPI:1245792969
Name:STALLWORTH, SHANIKA (CNA)
Entity type:Individual
Prefix:
First Name:SHANIKA
Middle Name:
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:466 E 46TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-5444
Mailing Address - Country:US
Mailing Address - Phone:904-334-0115
Mailing Address - Fax:
Practice Address - Street 1:466 E 46TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-5444
Practice Address - Country:US
Practice Address - Phone:904-334-0115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA303138251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health