Provider Demographics
NPI:1720977952
Name:ANDERSON, SHATAURA
Entity type:Individual
Prefix:
First Name:SHATAURA
Middle Name:
Last Name:ANDERSON
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 1:12300 E US HIGHWAY 40 STE A
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6008
Mailing Address - Country:US
Mailing Address - Phone:725-335-5159
Mailing Address - Fax:
Practice Address - Street 1:12300 E US HIGHWAY 40 STE A
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6008
Practice Address - Country:US
Practice Address - Phone:725-335-5159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-01
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist