Provider Demographics
NPI:1679247852
Name:SCULL, SHARESE
Entity Type:Individual
Prefix:
First Name:SHARESE
Middle Name:
Last Name:SCULL
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 1:7832 N 46TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-4411
Mailing Address - Country:US
Mailing Address - Phone:414-943-2654
Mailing Address - Fax:
Practice Address - Street 1:7832 N 46TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-4411
Practice Address - Country:US
Practice Address - Phone:414-943-2654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI342000000X