Provider Demographics
NPI:1689448151
Name:STUKES, DEDRA SHATIA
Entity Type:Individual
Prefix:
First Name:DEDRA
Middle Name:SHATIA
Last Name:STUKES
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 1:539 W COMMERCE ST # 4922
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-1953
Mailing Address - Country:US
Mailing Address - Phone:833-336-6002
Mailing Address - Fax:
Practice Address - Street 1:100 N HENDERSON AVE APT 201
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214
Practice Address - Country:US
Practice Address - Phone:833-336-6002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory