Provider Demographics
NPI:1942950290
Name:SHELLEY, JEFFRREY CORNELIUS
Entity Type:Individual
Prefix:
First Name:JEFFRREY
Middle Name:CORNELIUS
Last Name:SHELLEY
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 1:504 GILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30145-1334
Mailing Address - Country:US
Mailing Address - Phone:770-769-8881
Mailing Address - Fax:
Practice Address - Street 1:504 GILL RD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:GA
Practice Address - Zip Code:30145-1334
Practice Address - Country:US
Practice Address - Phone:770-769-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN217906163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse