Provider Demographics
NPI:1265066815
Name:HURDLE, SHANEKA M (LPN)
Entity type:Individual
Prefix:MS
First Name:SHANEKA
Middle Name:M
Last Name:HURDLE
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 1:1011 HUFFINE MILL RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6239
Mailing Address - Country:US
Mailing Address - Phone:336-486-2562
Mailing Address - Fax:
Practice Address - Street 1:1011 HUFFINE MILL RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6239
Practice Address - Country:US
Practice Address - Phone:336-486-2562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-22
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
NC320600000X
NC85936164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1265066815Medicaid