Provider Demographics
NPI:1417416264
Name:KING, SHELLI SUE (LE)
Entity Type:Individual
Prefix:
First Name:SHELLI
Middle Name:SUE
Last Name:KING
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 PARK LAKE CT
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:CA
Mailing Address - Zip Code:95658-9491
Mailing Address - Country:US
Mailing Address - Phone:916-524-3284
Mailing Address - Fax:
Practice Address - Street 1:152 MAPLE ST STE A
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-5042
Practice Address - Country:US
Practice Address - Phone:916-524-3284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9577171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA3302918OtherCA ID