Provider Demographics
NPI:1689881179
Name:SHELLEY, GLENDA (LVN)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 LENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-4614
Mailing Address - Country:US
Mailing Address - Phone:806-352-1159
Mailing Address - Fax:806-352-1159
Practice Address - Street 1:3710 LENWOOD DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-4614
Practice Address - Country:US
Practice Address - Phone:806-352-1159
Practice Address - Fax:806-352-1159
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX135801164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1002412Medicaid