Provider Demographics
NPI:1750951877
Name:MOULTRY, SHERELLE
Entity type:Individual
Prefix:
First Name:SHERELLE
Middle Name:
Last Name:MOULTRY
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 1:1185 S ONEIDA ST APT C
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-3137
Mailing Address - Country:US
Mailing Address - Phone:720-216-7397
Mailing Address - Fax:
Practice Address - Street 1:3955 E EXPOSITION AVE STE 320
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-5033
Practice Address - Country:US
Practice Address - Phone:303-777-1151
Practice Address - Fax:303-777-1362
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONA.00705339374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide