MEDICARE: MRS. LA SHANDRA NICHELLE YOUNG REGISTERED NURSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0400X	Case Management Registered Nurse	139406	WI

General Provider Information

NPI Number	:	1689339293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LA SHANDRA NICHELLE YOUNG REGISTERED NURSE

Provider Business Mailing Address
First Line	:	PO BOX 76068
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-7668
Country	:	US
Telephone Number	:	414-403-1611
Fax Number	:

Provider Business Practice Location Address
First Line	:	5731 W ROOSEVELT DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-3155
Country	:	US
Telephone Number	:	414-403-1611
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2021
Last Update Date	:	11/08/2021

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