Provider Demographics
NPI:1487819264
Name:BARDLEY, SHERITA MICHELLE (FAMILY PRACTIONER)
Entity Type:Individual
Prefix:
First Name:SHERITA
Middle Name:MICHELLE
Last Name:BARDLEY
Suffix:
Gender:F
Credentials:FAMILY PRACTIONER
Other - Prefix:
Other - First Name:SHERITA
Other - Middle Name:MICHELLE
Other - Last Name:BARDLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FAMILY PRACTIONER
Mailing Address - Street 1:15922 ELDORADO PKWY STE 500
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-5880
Mailing Address - Country:US
Mailing Address - Phone:314-749-6675
Mailing Address - Fax:
Practice Address - Street 1:100 N TUCKER BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1931
Practice Address - Country:US
Practice Address - Phone:314-814-8515
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001014327363LF0000X, 364SF0001X
TXAP127914363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500899562Medicaid