Provider Demographics
NPI:1043832694
Name:WOODS, SHANIQUA DENISE
Entity type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:DENISE
Last Name:WOODS
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 1:4020 SAINT FERDINAND AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113-3242
Mailing Address - Country:US
Mailing Address - Phone:314-285-9132
Mailing Address - Fax:
Practice Address - Street 1:4020 SAINT FERDINAND AVE UNIT C
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-3242
Practice Address - Country:US
Practice Address - Phone:314-285-9132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-16
Last Update Date:2020-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO09172008Medicaid