Provider Demographics
NPI:1023592128
Name:O'TETER, SHELBY NICOLE
Entity type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:NICOLE
Last Name:O'TETER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SHELBY
Other - Middle Name:NICOLE
Other - Last Name:REESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 E ROYAL LN STE 290
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-3602
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:400 E ROYAL LN STE 290
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-3602
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-16-1798-42267247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty