Healthcare Provider Details

I. General information

NPI: 1629668520
Provider Name (Legal Business Name): SHANE DALY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 CAMDEN AVE
SALISBURY MD
21801-6837
US

IV. Provider business mailing address

244 ONLEY RD APT 105
SALISBURY MD
21804-7092
US

V. Phone/Fax

Practice location:
  • Phone: 240-702-4690
  • Fax:
Mailing address:
  • Phone: 240-702-4690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: