Healthcare Provider Details

I. General information

NPI: 1639992407
Provider Name (Legal Business Name): SHANITA DUDLEY GARNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 FERN VALLEY RD STE 204
LOUISVILLE KY
40213-3564
US

IV. Provider business mailing address

3215 FERN VALLEY RD STE 204
LOUISVILLE KY
40213-3564
US

V. Phone/Fax

Practice location:
  • Phone: 502-975-5930
  • Fax:
Mailing address:
  • Phone: 502-975-5930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number500439
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number500439
License Number State
# 4
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number500439
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: