Provider Demographics
NPI:1831799683
Name:BLACK, SHAWNIECE (RN)
Entity type:Individual
Prefix:
First Name:SHAWNIECE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7442 HENDRICKS ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-4452
Mailing Address - Country:US
Mailing Address - Phone:219-381-9709
Mailing Address - Fax:
Practice Address - Street 1:7442 HENDRICKS ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-4452
Practice Address - Country:US
Practice Address - Phone:219-381-9709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2024-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28250967A251E00000X, 251J00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care