Healthcare Provider Details

I. General information

NPI: 1760096671
Provider Name (Legal Business Name): SHASTA DAWN WHITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 BOWSER RD
GALLIPOLIS FERRY WV
25515-6557
US

IV. Provider business mailing address

154 BOWSER RD
GALLIPOLIS FERRY WV
25515-6557
US

V. Phone/Fax

Practice location:
  • Phone: 681-237-0144
  • Fax:
Mailing address:
  • Phone: 681-237-0144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: