Provider Demographics
NPI:1477661031
Name:SHEALY, JERRI LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JERRI
Middle Name:LYNN
Last Name:SHEALY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JERRI
Other - Middle Name:LYNN
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:119 AMICKS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-8370
Mailing Address - Country:US
Mailing Address - Phone:803-932-2200
Mailing Address - Fax:803-932-2225
Practice Address - Street 1:119 AMICKS FERRY RD.
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036
Practice Address - Country:US
Practice Address - Phone:803-932-2200
Practice Address - Fax:803-932-2225
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18804208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC188040Medicaid