MEDICARE: SHAMPAYNE FENTRESS-CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	372600000X	Adult Companion	25006459	NE
2	3747P1801X	Personal Care Attendant
3	372500000X	Chore Provider	25006459	NE

General Provider Information

NPI Number	:	1659165272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAMPAYNE FENTRESS-CLARK

Provider Business Mailing Address
First Line	:	3030 MEREDITH AVE UNIT 111024
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68111-2446
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4932 CALIFORNIA ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68132-2418
Country	:	US
Telephone Number	:	402-830-1088
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2025
Last Update Date	:	04/08/2025

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Directions to “ SHAMPAYNE FENTRESS-CLARK ” Practice Location

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