Provider Demographics
NPI:1730838756
Name:DECOSTA, SHANIKKA M
Entity type:Individual
Prefix:
First Name:SHANIKKA
Middle Name:M
Last Name:DECOSTA
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 1:1615 MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-8100
Mailing Address - Country:US
Mailing Address - Phone:190-425-0492
Mailing Address - Fax:
Practice Address - Street 1:1615 MORGAN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-8100
Practice Address - Country:US
Practice Address - Phone:190-425-0492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty