Provider Demographics
NPI:1912355108
Name:WHEELER, SHAVONTE
Entity Type:Individual
Prefix:
First Name:SHAVONTE
Middle Name:
Last Name:WHEELER
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 1:136 KINGSBERRY DR
Mailing Address - Street 2:APT C
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-2236
Mailing Address - Country:US
Mailing Address - Phone:585-208-0298
Mailing Address - Fax:
Practice Address - Street 1:136 KINGSBERRY DR
Practice Address - Street 2:APT C
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-2236
Practice Address - Country:US
Practice Address - Phone:585-208-0298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY323755-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse