Healthcare Provider Details

I. General information

NPI: 1215098512
Provider Name (Legal Business Name): LA NEICE LORRAINE ABDEL-SHAKUR CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LA NEICE LORRAINE PERKINS CNM

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR DAVID GRANT MEDICAL CENTER
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

101 BODIN CIR WOMEN'S HEALTH
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-5406
  • Fax: 707-423-7356
Mailing address:
  • Phone: 707-423-5406
  • Fax: 707-423-7356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License Number704600
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number1906
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: