Healthcare Provider Details

I. General information

NPI: 1073041497
Provider Name (Legal Business Name): SHELLEY PROCTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2017
Last Update Date: 03/04/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N CLEMENTINE ST
OCEANSIDE CA
92054-2806
US

IV. Provider business mailing address

3920 HOLLY BRAE LN
CARLSBAD CA
92008-2725
US

V. Phone/Fax

Practice location:
  • Phone: 760-477-4754
  • Fax:
Mailing address:
  • Phone: 760-803-7518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: