MEDICARE: SHEMEKA HENDRIETH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN5166356	FL

General Provider Information

NPI Number	:	1861034886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHEMEKA HENDRIETH

Provider Business Mailing Address
First Line	:	968 REDWOOD ST
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-4572
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	968 REDWOOD ST
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-4572
Country	:	US
Telephone Number	:	386-238-5706
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2019
Last Update Date	:	10/10/2019

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Directions to “ SHEMEKA HENDRIETH ” Practice Location

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