MEDICARE: SHENNEKKA BOYD LVN

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	164X00000X	Licensed Vocational Nurse	713713	CA

General Provider Information

NPI Number	:	1780342709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHENNEKKA BOYD LVN

Provider Business Mailing Address
First Line	:	14713 STEALTH WAY
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92553-3516
Country	:	US
Telephone Number	:	951-591-4588
Fax Number	:

Provider Business Practice Location Address
First Line	:	14713 STEALTH WAY
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92553-3516
Country	:	US
Telephone Number	:	951-591-4588
Fax Number	:

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

Provider Enumeration Date	:	12/07/2021
Last Update Date	:	12/07/2021

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