Provider Demographics
NPI:1972862704
Name:SHIVES, SUE ELLEN (RN)
Entity Type:Individual
Prefix:MS
First Name:SUE
Middle Name:ELLEN
Last Name:SHIVES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:SUE
Other - Middle Name:ELLEN
Other - Last Name:FOCKLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:11902 SAINT PAUL RD
Mailing Address - Street 2:
Mailing Address - City:CLEAR SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:21722-1946
Mailing Address - Country:US
Mailing Address - Phone:301-842-2548
Mailing Address - Fax:
Practice Address - Street 1:11902 SAINT PAUL RD
Practice Address - Street 2:
Practice Address - City:CLEAR SPRING
Practice Address - State:MD
Practice Address - Zip Code:21722-1946
Practice Address - Country:US
Practice Address - Phone:301-842-2548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR173386163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse