Provider Demographics
NPI:1629088596
Name:STANLEY, SHIRLEY A
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:A
Last Name:STANLEY
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 1:720 N PERSON ST
Mailing Address - Street 2:#106
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1277
Mailing Address - Country:US
Mailing Address - Phone:205-307-9200
Mailing Address - Fax:
Practice Address - Street 1:720 N PERSON ST
Practice Address - Street 2:#106
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1277
Practice Address - Country:US
Practice Address - Phone:205-307-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1024857367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000073806Medicaid
NCAPPROVED 07/13/2011;Medicaid
AL430017465OtherRR MEDICARE
AL430063126OtherRR MEDICARE
NCNC0300AMedicare UPIN
AL000073806Medicaid