Provider Demographics
NPI:1215661061
Name:HARRIS, NICOSHA SHANAE
Entity type:Individual
Prefix:
First Name:NICOSHA
Middle Name:SHANAE
Last Name:HARRIS
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 1:704 W NATIONAL AVE APT 140
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-1742
Mailing Address - Country:US
Mailing Address - Phone:414-243-6647
Mailing Address - Fax:
Practice Address - Street 1:704 W NATIONAL AVE APT 140
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-1742
Practice Address - Country:US
Practice Address - Phone:414-243-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X, 261QC1500X
WI376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No376K00000XNursing Service Related ProvidersNurse's Aide
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program