Provider Demographics
NPI:1932864550
Name:COBB, SHANTRELL NICOLE
Entity Type:Individual
Prefix:
First Name:SHANTRELL
Middle Name:NICOLE
Last Name:COBB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANTRELL
Other - Middle Name:NICOLE
Other - Last Name:COBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:623 LONG BRANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-6252
Mailing Address - Country:US
Mailing Address - Phone:904-582-6209
Mailing Address - Fax:
Practice Address - Street 1:623 LONG BRANCH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-6252
Practice Address - Country:US
Practice Address - Phone:904-571-7843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL238101376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1932864550Medicaid