Provider Demographics
NPI:1790404507
Name:COLES, SHADREKA L
Entity Type:Individual
Prefix:
First Name:SHADREKA
Middle Name:L
Last Name:COLES
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 1:2609 HUNTERS LN
Mailing Address - Street 2:
Mailing Address - City:BLAIRS
Mailing Address - State:VA
Mailing Address - Zip Code:24527-3019
Mailing Address - Country:US
Mailing Address - Phone:434-429-8078
Mailing Address - Fax:
Practice Address - Street 1:2609 HUNTERS LN
Practice Address - Street 2:
Practice Address - City:BLAIRS
Practice Address - State:VA
Practice Address - Zip Code:24527-3019
Practice Address - Country:US
Practice Address - Phone:434-429-8078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA11418530261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care