Healthcare Provider Details

I. General information

NPI: 1598153819
Provider Name (Legal Business Name): COCOANISHA SHEANTA MATLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 STARLITE DR NW
WARREN OH
44485-1618
US

IV. Provider business mailing address

3100 STARLITE DR NW
WARREN OH
44485-1618
US

V. Phone/Fax

Practice location:
  • Phone: 216-371-9858
  • Fax:
Mailing address:
  • Phone: 216-371-9858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number501134600606
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: