=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528783065
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LATRICE JANIVA SHELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2022
-----------------------------------------------------
Last Update Date | 02/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 EASTGATE DR
-----------------------------------------------------
City | AIKEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29803-7688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-643-3694
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 FIOLI CIR
-----------------------------------------------------
City | GRANITEVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29829-3916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-243-1088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | GAA-NP001142
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | F10220365
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------