Provider Demographics
NPI:1881077824
Name:SHANLEY, AGNES
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:SHANLEY
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 1:926 WOODMERE DR
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-5543
Mailing Address - Country:US
Mailing Address - Phone:732-500-3191
Mailing Address - Fax:
Practice Address - Street 1:3 CORBETT WAY
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-2283
Practice Address - Country:US
Practice Address - Phone:732-500-3191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00741200225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist