Provider Demographics
NPI:1053969139
Name:CHURCH, SHERMAINE CIERRA
Entity type:Individual
Prefix:
First Name:SHERMAINE
Middle Name:CIERRA
Last Name:CHURCH
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 1:3469 SAINT MARK LN
Mailing Address - Street 2:
Mailing Address - City:SAINT ANN
Mailing Address - State:MO
Mailing Address - Zip Code:63074-2909
Mailing Address - Country:US
Mailing Address - Phone:314-201-7661
Mailing Address - Fax:
Practice Address - Street 1:3469 SAINT MARK LN
Practice Address - Street 2:
Practice Address - City:SAINT ANN
Practice Address - State:MO
Practice Address - Zip Code:63074-2909
Practice Address - Country:US
Practice Address - Phone:314-201-7661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-31
Last Update Date:2019-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOW137166001172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO84-2671703Medicaid