Provider Demographics
NPI:1932646114
Name:MAURO, SHELLY (RN)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:MAURO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 ROLLING BROOK DR
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3619
Mailing Address - Country:US
Mailing Address - Phone:518-885-8574
Mailing Address - Fax:
Practice Address - Street 1:38 ROLLING BROOK DR
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-3619
Practice Address - Country:US
Practice Address - Phone:518-885-8574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22 582415163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1659437630Medicaid