Healthcare Provider Details

I. General information

NPI: 1588324727
Provider Name (Legal Business Name): SHARONDA A COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2021
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 BELLEFONTAINE RD
SAINT LOUIS MO
63137-1336
US

IV. Provider business mailing address

5132 N ELSTON AVE
CHICAGO IL
60630-2429
US

V. Phone/Fax

Practice location:
  • Phone: 314-388-0796
  • Fax:
Mailing address:
  • Phone: 847-235-6130
  • Fax: 847-941-0577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209023715
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021021440
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: