Provider Demographics
NPI:1447869516
Name:GODFREY, SHANA
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:GODFREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 POINSETTIA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSAMOND
Mailing Address - State:CA
Mailing Address - Zip Code:93560-7432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 POINSETTIA AVE
Practice Address - Street 2:
Practice Address - City:ROSAMOND
Practice Address - State:CA
Practice Address - Zip Code:93560-7432
Practice Address - Country:US
Practice Address - Phone:323-898-9507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA697716164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse