Provider Demographics
NPI:1144946492
Name:WEBSTER, SHATIVIUS C (CNA)
Entity type:Individual
Prefix:
First Name:SHATIVIUS
Middle Name:C
Last Name:WEBSTER
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 1:1717 ORANGE AVE UNIT 1523
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34954-3365
Mailing Address - Country:US
Mailing Address - Phone:772-243-1149
Mailing Address - Fax:
Practice Address - Street 1:1103 N 13TH ST APT A
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-3218
Practice Address - Country:US
Practice Address - Phone:772-243-1149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA399484163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health