Provider Demographics
NPI:1225155518
Name:SHELTON, BEVERLY LYNN
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:LYNN
Last Name:SHELTON
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 1:1165 MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2518
Mailing Address - Country:US
Mailing Address - Phone:937-592-0545
Mailing Address - Fax:
Practice Address - Street 1:1165 MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2518
Practice Address - Country:US
Practice Address - Phone:937-592-0545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2670024Medicaid