Healthcare Provider Details

I. General information

NPI: 1487226403
Provider Name (Legal Business Name): SHIKINA LATRICE DE VEAUX SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3791 LAVISTA RD APT 3
TUCKER GA
30084-5675
US

IV. Provider business mailing address

3791 LAVISTA RD APT 3
TUCKER GA
30084-5675
US

V. Phone/Fax

Practice location:
  • Phone: 334-444-0069
  • Fax:
Mailing address:
  • Phone: 334-444-0069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO134695
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: