Provider Demographics
NPI:1174856678
Name:MALLORY, SHANELL MELISSA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:SHANELL
Middle Name:MELISSA
Last Name:MALLORY
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 1:815 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6507
Mailing Address - Country:US
Mailing Address - Phone:440-452-1353
Mailing Address - Fax:
Practice Address - Street 1:815 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6507
Practice Address - Country:US
Practice Address - Phone:440-452-1353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 102168164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse