Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 0618002671 | VA |
NPI | 1013484260 |
---|---|
Provider Name | Shanelle Jenkins |
First Address | Charlotte, NC 28227-5937 |
Second Address | Daytona Beach, FL 32114-1495 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2018 |
Last Update Date | 25/10/2018 |