Provider Demographics
NPI:1992322952
Name:NICHOLSON, SHADEANA (CNA)
Entity type:Individual
Prefix:
First Name:SHADEANA
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 LARKIN ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-5024
Mailing Address - Country:US
Mailing Address - Phone:941-549-4120
Mailing Address - Fax:
Practice Address - Street 1:4227 LARKIN ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-5024
Practice Address - Country:US
Practice Address - Phone:941-549-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2023-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA225687376J00000X, 376K00000X, 374U00000X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107572700Medicaid