Provider Demographics
NPI:1386833879
Name:CLEVIDENCE, SHELLY (ND)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:
Last Name:CLEVIDENCE
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4722 SE TOLMAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6932
Mailing Address - Country:US
Mailing Address - Phone:503-319-1901
Mailing Address - Fax:
Practice Address - Street 1:3021 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1476
Practice Address - Country:US
Practice Address - Phone:503-319-1901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1516175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath