Healthcare Provider Details

I. General information

NPI: 1730851932
Provider Name (Legal Business Name): SHAVONDA LATRICE FIELDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1429 S KEDVALE AVE
CHICAGO IL
60623-1246
US

IV. Provider business mailing address

3473 S KING DR # 215
CHICAGO IL
60616-4108
US

V. Phone/Fax

Practice location:
  • Phone: 773-680-0710
  • Fax:
Mailing address:
  • Phone: 773-680-0710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberF432-5915-7927
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: