Provider Demographics
NPI:1043984065
Name:FAVOR, SHAMONIQUE (CNA)
Entity type:Individual
Prefix:
First Name:SHAMONIQUE
Middle Name:
Last Name:FAVOR
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 GINGEROOT WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6783
Mailing Address - Country:US
Mailing Address - Phone:803-238-1640
Mailing Address - Fax:
Practice Address - Street 1:206 GINGEROOT WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6783
Practice Address - Country:US
Practice Address - Phone:803-238-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC53966251J00000X
SC9986560251J00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care