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General NPI Number Information
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NPI Number | 1144816950
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Entity Type | Individual
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Provider Name | MS. SHANTELL CHONNE TUCKER
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Gender | Female
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Dates
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Enumeration Date | 12/16/2020
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Last Update Date | 02/26/2021
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Provider Practice Location Address
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Address Line | 9403 MANSFIELD RD
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City | SHREVEPORT
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State | LA
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Zip | 71118-3815
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Country | US
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Telephone | 318-861-8938
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Fax | 318-202-3707
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Provider Business Mailing Address
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Address Line | 1000 CHINABERRY DR STE 900
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City | BOSSIER CITY
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State | LA
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Zip | 71111-2455
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Country | US
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Telephone | 318-202-3706
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Fax | 318-202-3707
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number |
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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