Healthcare Provider Details

I. General information

NPI: 1972893469
Provider Name (Legal Business Name): SHELLEY NICOLE AVERETTE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 ETHEL AVE
DAYTON OH
45417-3659
US

IV. Provider business mailing address

925 ETHEL AVE
DAYTON OH
45417-3659
US

V. Phone/Fax

Practice location:
  • Phone: 937-510-2215
  • Fax:
Mailing address:
  • Phone: 937-510-2215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberPN. 127395
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: