Provider Demographics
NPI:1962258004
Name:GRAYBILL, SHAWNICE ODETTA
Entity type:Individual
Prefix:
First Name:SHAWNICE
Middle Name:ODETTA
Last Name:GRAYBILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAWNICE
Other - Middle Name:ODETTA
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:8105 SARATOGA WAY
Mailing Address - Street 2:SUITE 240
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762
Mailing Address - Country:US
Mailing Address - Phone:919-495-3253
Mailing Address - Fax:
Practice Address - Street 1:8105 SARATOGA WAY
Practice Address - Street 2:SUITE 240
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762
Practice Address - Country:US
Practice Address - Phone:919-495-3253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF04240329363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily