Provider Demographics
NPI:1740985662
Name:SHOCKLEY, SIERRA
Entity type:Individual
Prefix:
First Name:SIERRA
Middle Name:
Last Name:SHOCKLEY
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 1:200 W LIBERTY ST STE 1812
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2473
Mailing Address - Country:US
Mailing Address - Phone:314-218-0543
Mailing Address - Fax:
Practice Address - Street 1:500 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1702
Practice Address - Country:US
Practice Address - Phone:502-852-5193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health