Healthcare Provider Details

I. General information

NPI: 1962638197
Provider Name (Legal Business Name): SHELLEY ROSE WAITE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 HIGHLAND AVE
SALEM MA
01970-2141
US

IV. Provider business mailing address

57 HIGHLAND AVE
SALEM MA
01970-2141
US

V. Phone/Fax

Practice location:
  • Phone: 978-354-2795
  • Fax: 978-740-4748
Mailing address:
  • Phone: 978-354-2795
  • Fax: 978-740-4748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125-56149
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number247376
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: