Provider Demographics
NPI:1265869689
Name:THOMPSON, SHEVONNE LATRELL
Entity type:Individual
Prefix:MS
First Name:SHEVONNE
Middle Name:LATRELL
Last Name:THOMPSON
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 1:320 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-3028
Mailing Address - Country:US
Mailing Address - Phone:843-423-0896
Mailing Address - Fax:843-423-0296
Practice Address - Street 1:320 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571-3028
Practice Address - Country:US
Practice Address - Phone:843-423-0896
Practice Address - Fax:843-423-0296
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8643374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide