Provider Demographics
NPI:1699369421
Name:RICHARDSON, FATIMA SHANI
Entity type:Individual
Prefix:
First Name:FATIMA
Middle Name:SHANI
Last Name:RICHARDSON
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 1:1294 LEISURE DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-2211
Mailing Address - Country:US
Mailing Address - Phone:973-494-3128
Mailing Address - Fax:
Practice Address - Street 1:1294 LEISURE DR
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-2211
Practice Address - Country:US
Practice Address - Phone:973-494-3128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC48745164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse