Healthcare Provider Details

I. General information

NPI: 1629809736
Provider Name (Legal Business Name): CAROLINE MARY SHEA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2024
Last Update Date: 08/10/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 MADISON OAK DR STE 310
SAN ANTONIO TX
78258-4298
US

IV. Provider business mailing address

8931 SCENIC CRK
CONVERSE TX
78109-1682
US

V. Phone/Fax

Practice location:
  • Phone: 210-483-8883
  • Fax:
Mailing address:
  • Phone: 303-514-8331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1171095
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: