Provider Demographics
NPI:1801174701
Name:COLEMAN, SHATARA
Entity type:Individual
Prefix:
First Name:SHATARA
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 W HUBBARD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:344 W HUBBARD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-4407
Practice Address - Country:US
Practice Address - Phone:401-770-3433
Practice Address - Fax:401-652-9787
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003842A363LF0000X
IL277.001388363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71003842AOtherAPN
IL209008749OtherAPN-IL
IL277.001388OtherFPA-APN