Provider Demographics
NPI:1013787134
Name:MENIE, SHELBY DANE (LPN)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:DANE
Last Name:MENIE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4717
Mailing Address - Country:US
Mailing Address - Phone:918-348-4384
Mailing Address - Fax:
Practice Address - Street 1:300 W 5TH ST LOT 19
Practice Address - Street 2:
Practice Address - City:GORE
Practice Address - State:OK
Practice Address - Zip Code:74435-5377
Practice Address - Country:US
Practice Address - Phone:918-348-4384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0065513164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse