Provider Demographics
NPI:1801369897
Name:MAESHACK, KENYA SHANTELL
Entity Type:Individual
Prefix:
First Name:KENYA
Middle Name:SHANTELL
Last Name:MAESHACK
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 1:8120 CARDIGAN WAY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-4903
Mailing Address - Country:US
Mailing Address - Phone:318-294-1594
Mailing Address - Fax:
Practice Address - Street 1:7505 PINES RD STE 1104
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3900
Practice Address - Country:US
Practice Address - Phone:318-670-8313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator