Provider Demographics
NPI:1295363968
Name:IBE, SHADE ONYEMA MCKISSICK
Entity Type:Individual
Prefix:MRS
First Name:SHADE
Middle Name:ONYEMA MCKISSICK
Last Name:IBE
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 1:175 SCOTT SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-3124
Mailing Address - Country:US
Mailing Address - Phone:860-751-6265
Mailing Address - Fax:
Practice Address - Street 1:546 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-1604
Practice Address - Country:US
Practice Address - Phone:855-283-2156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1811520810Medicaid