Provider Demographics
NPI:1235608837
Name:DEPRIEST, SHARONDA
Entity Type:Individual
Prefix:
First Name:SHARONDA
Middle Name:
Last Name:DEPRIEST
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 1:1542 CORA DR
Mailing Address - Street 2:
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-2265
Mailing Address - Country:US
Mailing Address - Phone:142-388-8236
Mailing Address - Fax:
Practice Address - Street 1:1542 CORA DR
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-2265
Practice Address - Country:US
Practice Address - Phone:423-888-2362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000000000000251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN832498914Medicaid
TN83-2498914Medicaid