Healthcare Provider Details

I. General information

NPI: 1740884436
Provider Name (Legal Business Name): SHELLEY KAY TIJERINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11339 W UNIVERSITY BLVD
ODESSA TX
79764-9100
US

IV. Provider business mailing address

11339 W UNIVERSITY BLVD
ODESSA TX
79764-9100
US

V. Phone/Fax

Practice location:
  • Phone: 432-288-4172
  • Fax:
Mailing address:
  • Phone: 432-288-4172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: