Provider Demographics
NPI:1881132009
Name:KING, SHELLY ELAINE (008842)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:ELAINE
Last Name:KING
Suffix:
Gender:F
Credentials:008842
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8032 EAGLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-1973
Mailing Address - Country:US
Mailing Address - Phone:317-937-4551
Mailing Address - Fax:
Practice Address - Street 1:8032 EAGLE RIDGE DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-1973
Practice Address - Country:US
Practice Address - Phone:317-937-4551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH.008842172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker