Provider Demographics
NPI:1467930586
Name:SHELTON, JULIANNE RENE (OD)
Entity Type:Individual
Prefix:DR
First Name:JULIANNE
Middle Name:RENE
Last Name:SHELTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 NORMANDY CIR
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-2431
Mailing Address - Country:US
Mailing Address - Phone:315-380-2110
Mailing Address - Fax:
Practice Address - Street 1:3333 MAPLE AVE STE 2
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:NY
Practice Address - Zip Code:13142-2548
Practice Address - Country:US
Practice Address - Phone:315-298-6966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008831152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYTUV008831OtherOPTOMETRY LICENSE