Provider Demographics
NPI:1801313390
Name:HARRIS, SHANTRELL
Entity type:Individual
Prefix:
First Name:SHANTRELL
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANTRELL
Other - Middle Name:
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 12777
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-0777
Mailing Address - Country:US
Mailing Address - Phone:904-418-4781
Mailing Address - Fax:904-485-8167
Practice Address - Street 1:1151 W 29TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-4015
Practice Address - Country:US
Practice Address - Phone:904-418-4781
Practice Address - Fax:904-485-8167
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care