=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174440648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHIEATA WADE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2026
-----------------------------------------------------
Last Update Date | 07/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9608 W EL CAMINITO DR
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85345-7739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-621-6258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9608 W EL CAMINITO DR
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85345-7739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-621-6258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------