Provider Demographics
NPI:1740035914
Name:SHORES, HEATHER MICHELLE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE
Last Name:SHORES
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 1:14651 GARY RD
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-8143
Mailing Address - Country:US
Mailing Address - Phone:580-263-4305
Mailing Address - Fax:
Practice Address - Street 1:501 N 1ST ST
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-1406
Practice Address - Country:US
Practice Address - Phone:580-798-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist