Provider Demographics
NPI:1356121669
Name:HENLEY, SHANE WADE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:WADE
Last Name:HENLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 SHIRLEE AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-1423
Mailing Address - Country:US
Mailing Address - Phone:405-332-3128
Mailing Address - Fax:
Practice Address - Street 1:1624 CIMARRON PLZ
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-3467
Practice Address - Country:US
Practice Address - Phone:844-458-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist