Provider Demographics
NPI:1619793486
Name:SHUFORD, SHANITA ROSHAWN (MEDICAL WIG PROVIDER)
Entity type:Individual
Prefix:MISS
First Name:SHANITA
Middle Name:ROSHAWN
Last Name:SHUFORD
Suffix:
Gender:F
Credentials:MEDICAL WIG PROVIDER
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 6602 STATESVILLE NC 28687
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687
Mailing Address - Country:US
Mailing Address - Phone:980-316-8921
Mailing Address - Fax:
Practice Address - Street 1:125 N TRADO ST SUITE D
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677
Practice Address - Country:US
Practice Address - Phone:828-571-8564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier