Provider Demographics
NPI:1689339293
Name:YOUNG, LA SHANDRA NICHELLE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:LA SHANDRA
Middle Name:NICHELLE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 76068
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-7668
Mailing Address - Country:US
Mailing Address - Phone:414-403-1611
Mailing Address - Fax:
Practice Address - Street 1:5731 W ROOSEVELT DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-3155
Practice Address - Country:US
Practice Address - Phone:414-403-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI139406163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management