Provider Demographics
NPI:1912954561
Name:SHIRLEY, MINTA J (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MINTA
Middle Name:J
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2830 VICTORY PKWY
Mailing Address - Street 2:LL-30
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1785
Mailing Address - Country:US
Mailing Address - Phone:513-245-3637
Mailing Address - Fax:513-475-7259
Practice Address - Street 1:222 PIEDMONT AVE
Practice Address - Street 2:SUITE 3200
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-4231
Practice Address - Country:US
Practice Address - Phone:513-475-8730
Practice Address - Fax:513-475-8033
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAAP03741363LF0000X
OHCOA.13367-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78007200Medicaid
KY1280120Medicare ID - Type Unspecified
KYP25522Medicare UPIN
KY78007200Medicaid