Provider Demographics
NPI:1467004259
Name:WILLIAMS-SCOTT, SHAKIDREA
Entity Type:Individual
Prefix:
First Name:SHAKIDREA
Middle Name:
Last Name:WILLIAMS-SCOTT
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 1:1409 WASHINGTON AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1913
Mailing Address - Country:US
Mailing Address - Phone:314-405-8884
Mailing Address - Fax:314-376-4580
Practice Address - Street 1:1409 WASHINGTON AVE STE 304
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1913
Practice Address - Country:US
Practice Address - Phone:314-405-8884
Practice Address - Fax:314-376-4580
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1770953556Medicaid