Provider Demographics
NPI:1518619881
Name:WARREN, SHAUNTAVIA
Entity Type:Individual
Prefix:
First Name:SHAUNTAVIA
Middle Name:
Last Name:WARREN
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 1:310 2ND ST SE STE 1416
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3957
Mailing Address - Country:US
Mailing Address - Phone:701-818-5658
Mailing Address - Fax:
Practice Address - Street 1:813 18TH AVE SE APT 402
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6746
Practice Address - Country:US
Practice Address - Phone:701-818-5658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND0000000000Medicaid