Provider Demographics
NPI:1265085906
Name:CAVALLO, SHELLEY A (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:A
Last Name:CAVALLO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HOLLY HILL LN
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:MA
Mailing Address - Zip Code:02359-3117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 WELLESLEY ST STE 1
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:MA
Practice Address - Zip Code:02493-1571
Practice Address - Country:US
Practice Address - Phone:617-909-5942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2260450363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health