Provider Demographics
NPI:1174114441
Name:CARTER, SHAMIA N
Entity type:Individual
Prefix:
First Name:SHAMIA
Middle Name:N
Last Name:CARTER
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 1:2812 RUTGER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1836
Mailing Address - Country:US
Mailing Address - Phone:314-484-3260
Mailing Address - Fax:844-274-1077
Practice Address - Street 1:2812 RUTGER ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1836
Practice Address - Country:US
Practice Address - Phone:314-484-3260
Practice Address - Fax:844-274-1077
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOLC001483952Medicaid
MO823629745Medicaid