Provider Demographics
NPI:1093712234
Name:SHAMLIN, KENYATTA D (MD)
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:D
Last Name:SHAMLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8490 PICARDY AVE
Mailing Address - Street 2:BLDG 200
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3731
Mailing Address - Country:US
Mailing Address - Phone:225-237-1754
Mailing Address - Fax:225-237-1722
Practice Address - Street 1:8595 PICARDY AVE
Practice Address - Street 2:STE 100
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3674
Practice Address - Country:US
Practice Address - Phone:225-763-4900
Practice Address - Fax:225-763-4938
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025911208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA110243989OtherRAILROAD MEDICARE
LA1136247Medicaid
LA4E676B116Medicare PIN
LA1136247Medicaid