Provider Demographics
NPI:1619390937
Name:REEVES, SHAYLENE
Entity Type:Individual
Prefix:
First Name:SHAYLENE
Middle Name:
Last Name:REEVES
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 1:233 GOODING ST N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6179
Mailing Address - Country:US
Mailing Address - Phone:208-736-5048
Mailing Address - Fax:208-735-2126
Practice Address - Street 1:233 GOODING ST N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6179
Practice Address - Country:US
Practice Address - Phone:208-736-5048
Practice Address - Fax:208-735-2126
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1558606962Medicaid