Provider Demographics
NPI:1952915266
Name:SHOCKEY, MARY ALICE
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALICE
Last Name:SHOCKEY
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 1:405 W GRAVEL LN
Mailing Address - Street 2:
Mailing Address - City:ROMNEY
Mailing Address - State:WV
Mailing Address - Zip Code:26757-1717
Mailing Address - Country:US
Mailing Address - Phone:304-822-7889
Mailing Address - Fax:
Practice Address - Street 1:24781 NORTHWESTERN PIKE
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-2675
Practice Address - Country:US
Practice Address - Phone:304-822-4030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant