Provider Demographics
NPI:1750972790
Name:ELLISON, SHAVAHNA LANAY
Entity type:Individual
Prefix:
First Name:SHAVAHNA
Middle Name:LANAY
Last Name:ELLISON
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 1:756 SHELL AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-3249
Mailing Address - Country:US
Mailing Address - Phone:209-681-1211
Mailing Address - Fax:
Practice Address - Street 1:758 SHELL AVE APT 1
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-3250
Practice Address - Country:US
Practice Address - Phone:916-410-5664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care