Provider Demographics
NPI:1649540261
Name:BOROM, SHIRLEY (RN)
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:
Last Name:BOROM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-1704
Mailing Address - Country:US
Mailing Address - Phone:219-882-5565
Mailing Address - Fax:219-882-8213
Practice Address - Street 1:1145 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1704
Practice Address - Country:US
Practice Address - Phone:219-882-5565
Practice Address - Fax:219-882-8213
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28093654A163W00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100142050AMedicaid