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
State | License ID | Taxonomies |
---|---|---|
OH | NP08368 | 363L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 000000475788 | Other | ANTHEM |
OH | 2614559 | Medicaid | |
OH | P00301721 | Other | RRMC |
OH | PENDING | Other | ANTHEM |
OH | PENDING | Other | ANTHEM |
OH | 2614559 | Medicaid | |
OH | 2614559 | Medicaid |