Provider Demographics
NPI:1871638551
Name:SHEA, PRISCILLA MARIE (DC)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:MARIE
Last Name:SHEA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 FOREST FALLS DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-6936
Mailing Address - Country:US
Mailing Address - Phone:207-846-1481
Mailing Address - Fax:207-846-7812
Practice Address - Street 1:10 FOREST FALLS DR
Practice Address - Street 2:SUITE 3
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6936
Practice Address - Country:US
Practice Address - Phone:207-846-1481
Practice Address - Fax:207-846-7812
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME831111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMNT457OtherHARVARD PILGRIM ID #
ME010462305001OtherFEDERAL TAX ID
ME014270OtherANTHEM STAR #
ME3783182OtherAETNA PROVIDER #
MEMNT457OtherHARVARD PILGRIM ID #
MM3661Medicare ID - Type Unspecified