Provider Demographics
NPI:1720841398
Name:MINK, SHELLY RAE
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RAE
Last Name:MINK
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 1:697 ACADEMY DR
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-8837
Mailing Address - Country:US
Mailing Address - Phone:937-689-4989
Mailing Address - Fax:
Practice Address - Street 1:697 ACADEMY DR
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:OH
Practice Address - Zip Code:43119-8837
Practice Address - Country:US
Practice Address - Phone:937-689-4989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker