Provider Demographics
NPI:1407032618
Name:BUMPERS, SHAUNTRICE (RN)
Entity Type:Individual
Prefix:MISS
First Name:SHAUNTRICE
Middle Name:
Last Name:BUMPERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 VETERAN MEMORIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301
Mailing Address - Country:US
Mailing Address - Phone:636-485-1173
Mailing Address - Fax:
Practice Address - Street 1:4000 JENNINGS STATION RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-3323
Practice Address - Country:US
Practice Address - Phone:636-485-1173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
MO2018030437163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018030437OtherREGISTERED NURSE