MEDICARE: SHELLY HARRIS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	686945	NY

General Provider Information

NPI Number	:	1487328860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLY HARRIS RN

Provider Business Mailing Address
First Line	:	8597 BALCOM CROSS RD
Second Line	:
City	:	SOUTH DAYTON
State	:	NY
Zip	:	14138-9610
Country	:	US
Telephone Number	:	716-785-0448
Fax Number	:

Provider Business Practice Location Address
First Line	:	42 LAKE ST STE D
Second Line	:
City	:	HAMBURG
State	:	NY
Zip	:	14075-4937
Country	:	US
Telephone Number	:	716-410-5390
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2021
Last Update Date	:	08/09/2021

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