Provider Demographics
NPI:1336533272
Name:SHAVER, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:SHAVER
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 1:25083 WATSON RANCH RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-3577
Mailing Address - Country:US
Mailing Address - Phone:936-689-6244
Mailing Address - Fax:
Practice Address - Street 1:110 MEMORIAL HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-4940
Practice Address - Country:US
Practice Address - Phone:936-291-4547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127649363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily