Provider Demographics
NPI:1245901289
Name:TOLLIVER, SHEMIKA SQUARE
Entity type:Individual
Prefix:
First Name:SHEMIKA
Middle Name:SQUARE
Last Name:TOLLIVER
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 1:10566 BIRCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70807-2928
Mailing Address - Country:US
Mailing Address - Phone:225-207-2580
Mailing Address - Fax:
Practice Address - Street 1:10566 BIRCHWOOD DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70807-2928
Practice Address - Country:US
Practice Address - Phone:225-207-2580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7069492172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver