Provider Demographics
NPI:1558038448
Name:PUCKERIN, SHELLY ANN ELA
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN ELA
Last Name:PUCKERIN
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 1:22 OLD CANAL DR
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-2730
Mailing Address - Country:US
Mailing Address - Phone:978-452-5155
Mailing Address - Fax:978-937-8177
Practice Address - Street 1:22 OLD CANAL DR
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851-2730
Practice Address - Country:US
Practice Address - Phone:978-452-5155
Practice Address - Fax:978-937-8177
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN98185164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse