MEDICARE: SHAKIRA TATJANA AUTRY

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	171M00000X	Case Manager/Care Coordinator
2	225400000X	Rehabilitation Practitioner		CA

General Provider Information

NPI Number	:	1801636378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAKIRA TATJANA AUTRY

Provider Business Mailing Address
First Line	:	2815 W AVENUE K12 APT 170
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93536-1141
Country	:	US
Telephone Number	:	661-779-3154
Fax Number	:

Provider Business Practice Location Address
First Line	:	348 E AVENUE K4
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93535-4505
Country	:	US
Telephone Number	:	661-310-6079
Fax Number	:

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

Provider Enumeration Date	:	05/30/2024
Last Update Date	:	04/10/2026

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