MEDICARE: SHAVONDA LATRICE FIELDS

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	172A00000X	Driver	F432-5915-7927	IL
2	101YP1600X	Pastoral Counselor
3	251S00000X	Community/Behavioral Health Agency
4	347C00000X	Private Vehicle
5	372600000X	Adult Companion

General Provider Information

NPI Number	:	1730851932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAVONDA LATRICE FIELDS

Provider Business Mailing Address
First Line	:	3473 S KING DR # 215
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-4108
Country	:	US
Telephone Number	:	773-680-0710
Fax Number	:

Provider Business Practice Location Address
First Line	:	1429 S KEDVALE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-1246
Country	:	US
Telephone Number	:	773-680-0710
Fax Number	:

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

Provider Enumeration Date	:	10/05/2021
Last Update Date	:	10/05/2021

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Directions to “ SHAVONDA LATRICE FIELDS ” Practice Location

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