Provider Demographics
NPI:1477049534
Name:MATLOCK, SHAKEILA DEVAUGHN
Entity type:Individual
Prefix:MISS
First Name:SHAKEILA
Middle Name:DEVAUGHN
Last Name:MATLOCK
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 1:715 BELVEDERE AVE SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-4325
Mailing Address - Country:US
Mailing Address - Phone:330-766-1887
Mailing Address - Fax:
Practice Address - Street 1:715 BELVEDERE AVE SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-4325
Practice Address - Country:US
Practice Address - Phone:330-766-1887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401637600414376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide