Provider Demographics
NPI:1578329207
Name:SHEA, AUDREY DOROTHEA
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:DOROTHEA
Last Name:SHEA
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 1:1 LINCOLN PL
Mailing Address - Street 2:
Mailing Address - City:MONSON
Mailing Address - State:MA
Mailing Address - Zip Code:01057-1219
Mailing Address - Country:US
Mailing Address - Phone:413-544-3856
Mailing Address - Fax:
Practice Address - Street 1:356 SEWALL ST
Practice Address - Street 2:
Practice Address - City:LUDLOW
Practice Address - State:MA
Practice Address - Zip Code:01056-2850
Practice Address - Country:US
Practice Address - Phone:413-544-3856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1969246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other