Provider Demographics
NPI:1104132760
Name:BYRD, SHASTA MICHELLE (CNA)
Entity type:Individual
Prefix:MISS
First Name:SHASTA
Middle Name:MICHELLE
Last Name:BYRD
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 1:2726 OLD EAGLE LAKE WINTER HAVEN RD
Mailing Address - Street 2:LOT 4
Mailing Address - City:EAGLE LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:33839-5402
Mailing Address - Country:US
Mailing Address - Phone:863-595-6865
Mailing Address - Fax:
Practice Address - Street 1:91 SURF DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-5756
Practice Address - Country:US
Practice Address - Phone:863-325-8424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL156966374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide