Provider Demographics
NPI:1316693096
Name:FLETCHER, SHANIECKA NICOLE
Entity type:Individual
Prefix:
First Name:SHANIECKA
Middle Name:NICOLE
Last Name:FLETCHER
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 1:3001 THOROUGHBRED DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4298
Mailing Address - Country:US
Mailing Address - Phone:254-466-8666
Mailing Address - Fax:
Practice Address - Street 1:3001 THOROUGHBRED DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4298
Practice Address - Country:US
Practice Address - Phone:254-466-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX709220163W00000X
305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No163W00000XNursing Service ProvidersRegistered Nurse