Provider Demographics
NPI:1063632347
Name:SHELTON, KENT
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:SHELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 MCNAB PARKWAY AND MAIN
Mailing Address - Street 2:
Mailing Address - City:SAN MANUEL
Mailing Address - State:AZ
Mailing Address - Zip Code:85631
Mailing Address - Country:US
Mailing Address - Phone:520-385-2337
Mailing Address - Fax:520-385-2621
Practice Address - Street 1:711 MCNAB PARKWAY AND MAIN
Practice Address - Street 2:
Practice Address - City:SAN MANUEL
Practice Address - State:AZ
Practice Address - Zip Code:85631
Practice Address - Country:US
Practice Address - Phone:520-385-2337
Practice Address - Fax:520-385-2621
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0018251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)