Healthcare Provider Details

I. General information

NPI: 1912622002
Provider Name (Legal Business Name): SHAKETTA BAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7722 GRANT ST UNIT B
MERRILLVILLE IN
46410-5493
US

IV. Provider business mailing address

7722 GRANT ST UNIT B
MERRILLVILLE IN
46410-5493
US

V. Phone/Fax

Practice location:
  • Phone: 773-953-0785
  • Fax:
Mailing address:
  • Phone: 773-953-0785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberA8G5W2T3
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: