Provider Demographics
NPI:1619664711
Name:FOX, SHELLY RAE
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RAE
Last Name:FOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:
Other - Last Name:WHITLEY-WAELTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9615 GRAND RONDE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RONDE
Mailing Address - State:OR
Mailing Address - Zip Code:97347-9712
Mailing Address - Country:US
Mailing Address - Phone:503-879-2002
Mailing Address - Fax:
Practice Address - Street 1:9615 GRAND RONDE RD
Practice Address - Street 2:
Practice Address - City:GRAND RONDE
Practice Address - State:OR
Practice Address - Zip Code:97347-9712
Practice Address - Country:US
Practice Address - Phone:503-879-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000108778175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist