Provider Demographics
NPI:1902556103
Name:ISAAC, SHANACE (LPN)
Entity Type:Individual
Prefix:
First Name:SHANACE
Middle Name:
Last Name:ISAAC
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32145-0101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:629 DANIELS ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:FL
Practice Address - Zip Code:32145-3201
Practice Address - Country:US
Practice Address - Phone:904-293-5395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5252077164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty