Provider Demographics
NPI:1104608629
Name:DURRETT, SHANIQUA ROGERS (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:SHANIQUA
Middle Name:ROGERS
Last Name:DURRETT
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 1:1526 W 47TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-2047
Mailing Address - Country:US
Mailing Address - Phone:310-912-0252
Mailing Address - Fax:
Practice Address - Street 1:313 N LA BREA AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-3400
Practice Address - Country:US
Practice Address - Phone:310-912-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95053562163WI0500X, 163WH0200X, 163W00000X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WW0000XNursing Service ProvidersRegistered NurseWound Care