Healthcare Provider Details

I. General information

NPI: 1609416676
Provider Name (Legal Business Name): SHANTEL LATORIA CARSWELL LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2020
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1974 WALTON NICHOLSON PIKE
INDEPENDENCE KY
41051-7906
US

IV. Provider business mailing address

523 ROEBLING RD
CINCINNATI OH
45238-5529
US

V. Phone/Fax

Practice location:
  • Phone: 859-359-5404
  • Fax:
Mailing address:
  • Phone: 513-869-3911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2054476
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: