Healthcare Provider Details

I. General information

NPI: 1518619881
Provider Name (Legal Business Name): SHAUNTAVIA WARREN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 18TH AVE SE APT 402
MINOT ND
58701-6746
US

IV. Provider business mailing address

310 2ND ST SE STE 1416
MINOT ND
58701-3957
US

V. Phone/Fax

Practice location:
  • Phone: 701-818-5658
  • Fax:
Mailing address:
  • Phone: 701-818-5658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: