Provider Demographics
NPI:1922469204
Name:SHIFLETT, KEVIN JOHN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:SHIFLETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 LORRAINE ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1836
Mailing Address - Country:US
Mailing Address - Phone:518-572-9478
Mailing Address - Fax:
Practice Address - Street 1:42 LORRAINE ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1836
Practice Address - Country:US
Practice Address - Phone:518-572-9478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY649667163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse