Provider Demographics
NPI:1194419515
Name:ROBERTSON, SHANITA
Entity type:Individual
Prefix:
First Name:SHANITA
Middle Name:
Last Name:ROBERTSON
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 1:5101 SPRINGLAKE PKWY APT 1027
Mailing Address - Street 2:
Mailing Address - City:HALTOM CITY
Mailing Address - State:TX
Mailing Address - Zip Code:76117-1347
Mailing Address - Country:US
Mailing Address - Phone:817-470-1625
Mailing Address - Fax:
Practice Address - Street 1:5101 SPRINGLAKE PKWY APT 1027
Practice Address - Street 2:
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76117-1347
Practice Address - Country:US
Practice Address - Phone:817-470-1625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No172A00000XOther Service ProvidersDriver