1831227529 NPI number — MRS. SHANTISE N FIELDS MS, IMF-74108

Table of content: MRS. SHANTISE N FIELDS MS, IMF-74108 (NPI 1831227529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831227529 NPI number — MRS. SHANTISE N FIELDS MS, IMF-74108

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FIELDS
Provider First Name:
SHANTISE
Provider Middle Name:
N
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, IMF-74108
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIAMS
Provider Other First Name:
SHANTISE
Provider Other Middle Name:
N.
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
BA, MS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831227529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1721 GRIFFIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90031-3312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-221-4134
Provider Business Mailing Address Fax Number:
323-221-3231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1721 GRIFFIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90031-3312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-221-4134
Provider Business Practice Location Address Fax Number:
323-221-3231
Provider Enumeration Date:
03/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  IMF 74108 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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