Healthcare Provider Details

I. General information

NPI: 1194633065
Provider Name (Legal Business Name): SHELBY POULTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 FRANCIS PL
LATHAM NY
12110-1613
US

IV. Provider business mailing address

12 SCHONOWEE AVE APT 2
SCOTIA NY
12302-2430
US

V. Phone/Fax

Practice location:
  • Phone: 518-817-3789
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: