Provider Demographics
NPI:1992392666
Name:LEACH, SHELLIE S
Entity Type:Individual
Prefix:
First Name:SHELLIE
Middle Name:S
Last Name:LEACH
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 1:2750 CAMBA RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-9394
Mailing Address - Country:US
Mailing Address - Phone:740-418-9225
Mailing Address - Fax:
Practice Address - Street 1:2750 CAMBA RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9394
Practice Address - Country:US
Practice Address - Phone:740-418-9225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172A00000X, 376J00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver
No376J00000XNursing Service Related ProvidersHomemaker