Provider Demographics
NPI:1104384239
Name:EVANS, SHAKEIDRA
Entity Type:Individual
Prefix:
First Name:SHAKEIDRA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N THOMAS DR STE 1
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6503
Mailing Address - Country:US
Mailing Address - Phone:318-424-8345
Mailing Address - Fax:318-424-4417
Practice Address - Street 1:200 N THOMAS DR STE 1
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6503
Practice Address - Country:US
Practice Address - Phone:318-424-8345
Practice Address - Fax:318-424-4417
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator