=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932864550
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANTRELL NICOLE COBB
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2021
-----------------------------------------------------
Last Update Date | 07/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 623 LONG BRANCH BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32206-6252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-571-7843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 623 LONG BRANCH BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32206-6252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-582-6209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number | 238101
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------