Provider Demographics
NPI:1477161107
Name:SHELL, SUSIE
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:SHELL
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 1:154 BALTIC DR
Mailing Address - Street 2:
Mailing Address - City:WEBER CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24290-7324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:154 BALTIC DR
Practice Address - Street 2:
Practice Address - City:WEBER CITY
Practice Address - State:VA
Practice Address - Zip Code:24290-7324
Practice Address - Country:US
Practice Address - Phone:423-534-9396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider