Provider Demographics
NPI:1588324727
Name:COLEMAN, SHARONDA A
Entity type:Individual
Prefix:
First Name:SHARONDA
Middle Name:A
Last Name:COLEMAN
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 1:5132 N ELSTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2429
Mailing Address - Country:US
Mailing Address - Phone:847-235-6130
Mailing Address - Fax:847-941-0577
Practice Address - Street 1:9500 BELLEFONTAINE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63137-1336
Practice Address - Country:US
Practice Address - Phone:314-388-0796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023715363LF0000X
MO2021021440363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily