Healthcare Provider Details

I. General information

NPI: 1104540962
Provider Name (Legal Business Name): SHANICE NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BARRET AVE STE 301
LOUISVILLE KY
40204-1747
US

IV. Provider business mailing address

605 SCHOLAR HOUSE CT APT 301
LOUISVILLE KY
40217-1879
US

V. Phone/Fax

Practice location:
  • Phone: 502-457-6153
  • Fax:
Mailing address:
  • Phone: 502-457-6153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code246Y00000X
TaxonomyHealth Information Specialist/Technologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: