Provider Demographics
NPI:1457519688
Name:PALMER, SHELLY KAYE
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:KAYE
Last Name:PALMER
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 1:764 CREEKSIDE DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-9333
Mailing Address - Country:US
Mailing Address - Phone:541-990-1260
Mailing Address - Fax:
Practice Address - Street 1:764 CREEKSIDE DR SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9333
Practice Address - Country:US
Practice Address - Phone:541-990-1260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR873133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered