Provider Demographics
NPI:1639992407
Name:GARNER, SHANITA DUDLEY
Entity type:Individual
Prefix:
First Name:SHANITA
Middle Name:DUDLEY
Last Name:GARNER
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 1:3215 FERN VALLEY RD STE 204
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-3564
Mailing Address - Country:US
Mailing Address - Phone:502-975-5930
Mailing Address - Fax:
Practice Address - Street 1:3215 FERN VALLEY RD STE 204
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-3564
Practice Address - Country:US
Practice Address - Phone:502-975-5930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251G00000X
500439372600000X, 3747P1801X
KY500439253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251G00000XAgenciesHospice Care, Community Based
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant