Provider Demographics
NPI:1386009769
Name:MINTHORN, SHELLY ROSE
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ROSE
Last Name:MINTHORN
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 1:73265 CONFEDERATED WAY
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-9099
Mailing Address - Country:US
Mailing Address - Phone:541-966-9830
Mailing Address - Fax:541-278-7568
Practice Address - Street 1:73265 CONFEDERATED WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-9099
Practice Address - Country:US
Practice Address - Phone:541-966-9830
Practice Address - Fax:541-278-7568
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist