Provider Demographics
NPI:1811481963
Name:SERVICE, SHELLY-ANN (LPN)
Entity type:Individual
Prefix:MS
First Name:SHELLY-ANN
Middle Name:
Last Name:SERVICE
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 1:4723 CARPENTER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470-1014
Mailing Address - Country:US
Mailing Address - Phone:347-734-9926
Mailing Address - Fax:
Practice Address - Street 1:4723 CARPENTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10470-1014
Practice Address - Country:US
Practice Address - Phone:347-734-9926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3230531164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse