Provider Demographics
NPI:1215399688
Name:VAN WAVE, SHELLEY EATON (LPN)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:EATON
Last Name:VAN WAVE
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 1:3163 TOUBY RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-6912
Mailing Address - Country:US
Mailing Address - Phone:720-402-6771
Mailing Address - Fax:
Practice Address - Street 1:3163 TOUBY RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-6912
Practice Address - Country:US
Practice Address - Phone:720-402-6771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48436164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1215399688Medicaid