Provider Demographics
NPI:1780955930
Name:DAVIS, STARICA SHANELL (LPN)
Entity type:Individual
Prefix:
First Name:STARICA
Middle Name:SHANELL
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:STARICA
Other - Middle Name:SHANELL
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:25 CROSS GATES RD
Mailing Address - Street 2:
Mailing Address - City:GATES
Mailing Address - State:NY
Mailing Address - Zip Code:14606-3306
Mailing Address - Country:US
Mailing Address - Phone:585-285-9673
Mailing Address - Fax:
Practice Address - Street 1:25 CROSS GATES RD
Practice Address - Street 2:
Practice Address - City:GATES
Practice Address - State:NY
Practice Address - Zip Code:14606-3306
Practice Address - Country:US
Practice Address - Phone:585-285-9673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2874801164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse