Provider Demographics
NPI:1720560261
Name:SHADE, MICHELLE RENEE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:SHADE
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 1:1323 W KEETOOWAH ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3462
Mailing Address - Country:US
Mailing Address - Phone:918-708-3006
Mailing Address - Fax:918-777-9016
Practice Address - Street 1:1323 W KEETOOWAH ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3462
Practice Address - Country:US
Practice Address - Phone:918-708-3006
Practice Address - Fax:918-777-9016
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator