Provider Demographics
NPI:1629028477
Name:SHULL-DIENER, SALLY MAE (CNP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:MAE
Last Name:SHULL-DIENER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 W ALEXIS RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-1006
Mailing Address - Country:US
Mailing Address - Phone:419-843-8150
Mailing Address - Fax:419-479-2579
Practice Address - Street 1:4640 W ALEXIS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-1006
Practice Address - Country:US
Practice Address - Phone:419-843-8150
Practice Address - Fax:419-479-2579
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP08368363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000475788OtherANTHEM
OH2614559Medicaid
OHP00301721OtherRRMC
OHPENDINGOtherANTHEM
OHPENDINGOtherANTHEM
OH2614559Medicaid
OH2614559Medicaid