Provider Demographics
NPI:1710277876
Name:TATE, SHELLY MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:MARIE
Last Name:TATE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4357 COUNTY ROAD 10
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-9717
Mailing Address - Country:US
Mailing Address - Phone:419-551-5923
Mailing Address - Fax:
Practice Address - Street 1:4357 COUNTY ROAD 10
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-9717
Practice Address - Country:US
Practice Address - Phone:419-551-5923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN085307164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse