Provider Demographics
NPI:1669137436
Name:PATRICK, SHAUNETTA
Entity type:Individual
Prefix:
First Name:SHAUNETTA
Middle Name:
Last Name:PATRICK
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 1:1655 N 29TH ST APT 611
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-1955
Mailing Address - Country:US
Mailing Address - Phone:772-834-1513
Mailing Address - Fax:
Practice Address - Street 1:1655 N 29TH ST APT 611
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-1955
Practice Address - Country:US
Practice Address - Phone:772-834-1513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider