Provider Demographics
NPI:1922863794
Name:SHANLEY, DEBRA JOAN
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JOAN
Last Name:SHANLEY
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 1:2500 MOWRY AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1605
Mailing Address - Country:US
Mailing Address - Phone:510-790-1911
Mailing Address - Fax:510-505-1960
Practice Address - Street 1:2500 MOWRY AVE STE 130
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1605
Practice Address - Country:US
Practice Address - Phone:510-790-1911
Practice Address - Fax:510-505-1960
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52324224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter