Healthcare Provider Details

I. General information

NPI: 1649758897
Provider Name (Legal Business Name): KIAH SHUNNAE WHITFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9403 MANSFIELD RD
SHREVEPORT LA
71118-3815
US

IV. Provider business mailing address

9403 MANSFIELD RD
SHREVEPORT LA
71118-3815
US

V. Phone/Fax

Practice location:
  • Phone: 318-861-8938
  • Fax: 318-862-3554
Mailing address:
  • Phone: 318-861-8938
  • Fax: 318-862-3554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: