Provider Demographics
NPI:1275190902
Name:KELLEY, SHAWNA LYNN
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:LYNN
Last Name:KELLEY
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 1:18706 LANGLEY POND LN
Mailing Address - Street 2:
Mailing Address - City:NEW CANEY
Mailing Address - State:TX
Mailing Address - Zip Code:77357-1546
Mailing Address - Country:US
Mailing Address - Phone:832-416-3605
Mailing Address - Fax:
Practice Address - Street 1:18706 LANGLEY POND LN
Practice Address - Street 2:
Practice Address - City:NEW CANEY
Practice Address - State:TX
Practice Address - Zip Code:77357-1546
Practice Address - Country:US
Practice Address - Phone:832-416-3605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341392164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse