Provider Demographics
NPI:1982434635
Name:SHAKES, SHAKA (MSN)
Entity type:Individual
Prefix:
First Name:SHAKA
Middle Name:
Last Name:SHAKES
Suffix:
Gender:M
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 WENTWORTH DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-3239
Mailing Address - Country:US
Mailing Address - Phone:256-454-3260
Mailing Address - Fax:
Practice Address - Street 1:275 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-5903
Practice Address - Country:US
Practice Address - Phone:256-454-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-116694163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health