Provider Demographics
NPI:1417200502
Name:CLANCY, SHELLEY JOAN (RN, BSN, IBCLC,RLC)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:JOAN
Last Name:CLANCY
Suffix:
Gender:F
Credentials:RN, BSN, IBCLC,RLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 ROSELAND AVE
Mailing Address - Street 2:UNIT 901
Mailing Address - City:CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-5943
Mailing Address - Country:US
Mailing Address - Phone:201-739-4058
Mailing Address - Fax:
Practice Address - Street 1:105 ROSELAND AVE
Practice Address - Street 2:UNIT 901
Practice Address - City:CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-5943
Practice Address - Country:US
Practice Address - Phone:201-739-4058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ108-72946163WL0100X
NY541810-1163WL0100X
NJ26NR06350900163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12455215OtherCAQH