Provider Demographics
NPI:1720844749
Name:GUNN, SHANTE'LLE DER'RECKA
Entity Type:Individual
Prefix:MS
First Name:SHANTE'LLE
Middle Name:DER'RECKA
Last Name:GUNN
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 1:5028 WOODLAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-4758
Mailing Address - Country:US
Mailing Address - Phone:937-782-8433
Mailing Address - Fax:
Practice Address - Street 1:5028 WOODLAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-4758
Practice Address - Country:US
Practice Address - Phone:937-782-8433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401618320314251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care