Provider Demographics
NPI:1609168673
Name:MORTLEY, SHENEKA VACQUANA DESLEE (MD)
Entity Type:Individual
Prefix:
First Name:SHENEKA
Middle Name:VACQUANA DESLEE
Last Name:MORTLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 ROCK PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8652
Mailing Address - Country:US
Mailing Address - Phone:800-423-2111
Mailing Address - Fax:254-743-1569
Practice Address - Street 1:1651 ROCK PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845
Practice Address - Country:US
Practice Address - Phone:800-423-2111
Practice Address - Fax:254-743-1569
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN16022207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine