Provider Demographics
NPI:1730851932
Name:FIELDS, SHAVONDA LATRICE
Entity type:Individual
Prefix:
First Name:SHAVONDA
Middle Name:LATRICE
Last Name:FIELDS
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 1:3473 S KING DR # 215
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4108
Mailing Address - Country:US
Mailing Address - Phone:773-680-0710
Mailing Address - Fax:
Practice Address - Street 1:1429 S KEDVALE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-1246
Practice Address - Country:US
Practice Address - Phone:773-680-0710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILF432-5915-7927172A00000X
101YP1600X, 251S00000X, 347C00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriver
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No251S00000XAgenciesCommunity/Behavioral Health
No347C00000XTransportation ServicesPrivate VehicleGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty