Provider Demographics
NPI:1083066583
Name:SHANKLIN, LEQUITSHA
Entity Type:Individual
Prefix:MS
First Name:LEQUITSHA
Middle Name:
Last Name:SHANKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LEQUITSHA
Other - Middle Name:SHANKLIN
Other - Last Name:WARREN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:215 BRES AVE STE G
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5869
Mailing Address - Country:US
Mailing Address - Phone:318-509-8073
Mailing Address - Fax:
Practice Address - Street 1:215 BRES AVE STE G
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5869
Practice Address - Country:US
Practice Address - Phone:318-509-8073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator