Provider Demographics
NPI:1740478023
Name:HART, SHELLY ANN (LPN)
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:ANN
Last Name:HART
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5818 TOWNSHIP ROAD 105
Mailing Address - Street 2:
Mailing Address - City:MOUNT GILEAD
Mailing Address - State:OH
Mailing Address - Zip Code:43338-9688
Mailing Address - Country:US
Mailing Address - Phone:419-947-1503
Mailing Address - Fax:
Practice Address - Street 1:5818 TOWNSHIP ROAD 105
Practice Address - Street 2:
Practice Address - City:MOUNT GILEAD
Practice Address - State:OH
Practice Address - Zip Code:43338-9688
Practice Address - Country:US
Practice Address - Phone:419-947-1503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 090470164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse