Healthcare Provider Details

I. General information

NPI: 1053467290
Provider Name (Legal Business Name): SHARON DENISE SQUIRES REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

IV. Provider business mailing address

1445 TIMOTHY DR
MEMPHIS TN
38116-5141
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax:
Mailing address:
  • Phone: 901-396-9128
  • Fax: 901-348-0032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number068412
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: