Provider Demographics
NPI:1083374466
Name:PROVENCHER, SHELLEY
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:PROVENCHER
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 1:3616 EASTPOINTE DR APT 102
Mailing Address - Street 2:
Mailing Address - City:NORTHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:43619-2175
Mailing Address - Country:US
Mailing Address - Phone:419-261-7011
Mailing Address - Fax:
Practice Address - Street 1:3616 EASTPOINTE DR APT 102
Practice Address - Street 2:
Practice Address - City:NORTHWOOD
Practice Address - State:OH
Practice Address - Zip Code:43619-2175
Practice Address - Country:US
Practice Address - Phone:419-261-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker