Provider Demographics
NPI:1225694912
Name:SHADE, BRIDGET A (PARTNER)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:A
Last Name:SHADE
Suffix:
Gender:F
Credentials:PARTNER
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:M
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PARTNER
Mailing Address - Street 1:6546 HANCOCK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2157
Mailing Address - Country:US
Mailing Address - Phone:314-800-7213
Mailing Address - Fax:
Practice Address - Street 1:6546 HANCOCK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-2157
Practice Address - Country:US
Practice Address - Phone:314-800-7213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO374U00000X
MO83-4650541374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide