Basic Information
| Provider Information | |||||||||
| NPI: | 1144816950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | SHANTELL | ||||||||
| MiddleName: | CHONNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 CHINABERRY DR STE 900 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182023706 | ||||||||
| FaxNumber: | 3182023707 | ||||||||
| Practice Location | |||||||||
| Address1: | 9403 MANSFIELD RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711183815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188618938 | ||||||||
| FaxNumber: | 3182023707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2020 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | LA | N | Other Service Providers | Military Health Care Provider | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.