=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831350818
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAWNTAY LATRICE FORREST L.P.N
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2008
-----------------------------------------------------
Last Update Date | 06/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 BEE ST
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29401-5703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-870-1315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5751 SCOTT WHITE RD
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29449-6156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-870-1315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | P 40923
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------