Provider Demographics
NPI:1528783065
Name:SHELL, LATRICE JANIVA
Entity type:Individual
Prefix:
First Name:LATRICE
Middle Name:JANIVA
Last Name:SHELL
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 1:404 FIOLI CIR
Mailing Address - Street 2:
Mailing Address - City:GRANITEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29829-3916
Mailing Address - Country:US
Mailing Address - Phone:803-243-1088
Mailing Address - Fax:
Practice Address - Street 1:550 EASTGATE DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-7688
Practice Address - Country:US
Practice Address - Phone:803-643-3694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2025-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP001142363LF0000X
SCF10220365363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily