Basic Information
| Provider Information | |||||||||
| NPI: | 1932640018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | SHINIKA | ||||||||
| MiddleName: | LATRICE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 204 HAMPTON DR | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103966468 | ||||||||
| FaxNumber: | 3103393040 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 HAMPTON DR | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103966468 | ||||||||
| FaxNumber: | 3103393040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2017 | ||||||||
| LastUpdateDate: | 06/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | Other Service Providers | Community Health Worker | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.