Provider Demographics
NPI:1790308732
Name:GRATE, SHARDAE
Entity Type:Individual
Prefix:
First Name:SHARDAE
Middle Name:
Last Name:GRATE
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 1:6542 N MASCHER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-1040
Mailing Address - Country:US
Mailing Address - Phone:267-212-2954
Mailing Address - Fax:
Practice Address - Street 1:6542 N MASCHER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-1040
Practice Address - Country:US
Practice Address - Phone:267-212-2954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA40963601376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103732466-0001Medicaid