Provider Demographics
NPI:1427592427
Name:PAVIS, SHELLY MARIE
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:PAVIS
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 1:38863 COURTLAND DR
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7509
Mailing Address - Country:US
Mailing Address - Phone:440-525-3126
Mailing Address - Fax:
Practice Address - Street 1:38863 COURTLAND DR
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-7509
Practice Address - Country:US
Practice Address - Phone:440-525-3126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2263036172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker