Provider Demographics
NPI:1780196428
Name:WADE, SHIRLEY K
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:K
Last Name:WADE
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 1:31328 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:NUEVO
Mailing Address - State:CA
Mailing Address - Zip Code:92567-8949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40925 COUNTY CIRCLE DRIVE
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591
Practice Address - Country:US
Practice Address - Phone:951-600-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator