Provider Demographics
NPI:1053539726
Name:SHADE, CARLA ANN
Entity type:Individual
Prefix:MISS
First Name:CARLA
Middle Name:ANN
Last Name:SHADE
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 1:14 MYERS AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-1414
Mailing Address - Country:US
Mailing Address - Phone:419-564-6710
Mailing Address - Fax:
Practice Address - Street 1:462 BARTLEY AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903
Practice Address - Country:US
Practice Address - Phone:419-747-4702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2513748OtherIP NO