Provider Demographics
NPI:1043682453
Name:WILKES, SHELLY ROSE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:ROSE
Last Name:WILKES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 PARHAM DR APT 227
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7726
Mailing Address - Country:US
Mailing Address - Phone:817-495-4880
Mailing Address - Fax:214-235-0789
Practice Address - Street 1:3103 PARHAM DR APT 227
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7726
Practice Address - Country:US
Practice Address - Phone:817-495-4880
Practice Address - Fax:214-235-0789
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-24
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014024802164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse