Provider Demographics
NPI:1053814053
Name:THEUS, SHAEDERRICA
Entity Type:Individual
Prefix:
First Name:SHAEDERRICA
Middle Name:
Last Name:THEUS
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 1:5311 WENDEL DR
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-4813
Mailing Address - Country:US
Mailing Address - Phone:318-762-1281
Mailing Address - Fax:
Practice Address - Street 1:8640 COVE MEADOW LN
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-2330
Practice Address - Country:US
Practice Address - Phone:318-762-1281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081112616OtherDBA