Provider Demographics
NPI:1659929065
Name:SHECKLEY, MARY EVELYN (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:EVELYN
Last Name:SHECKLEY
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:EVELYN
Other - Last Name:MALINOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4741 RANDOLPH RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2919
Practice Address - Country:US
Practice Address - Phone:704-365-6730
Practice Address - Fax:704-365-6731
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant