Provider Demographics
NPI:1942866439
Name:GUILLORY, SHALEA
Entity Type:Individual
Prefix:
First Name:SHALEA
Middle Name:
Last Name:GUILLORY
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 1:2512 S 123RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-5837
Mailing Address - Country:US
Mailing Address - Phone:323-449-7559
Mailing Address - Fax:
Practice Address - Street 1:4300 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2619
Practice Address - Country:US
Practice Address - Phone:917-728-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty