Provider Demographics
NPI:1548634371
Name:WARREN, SHAWNTA
Entity type:Individual
Prefix:
First Name:SHAWNTA
Middle Name:
Last Name:WARREN
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 1:10907 TANEY DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-2561
Mailing Address - Country:US
Mailing Address - Phone:540-388-2821
Mailing Address - Fax:540-412-1195
Practice Address - Street 1:10907 TANEY DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-2561
Practice Address - Country:US
Practice Address - Phone:540-388-2821
Practice Address - Fax:540-412-1195
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT63456150171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications