Healthcare Provider Details

I. General information

NPI: 1871753368
Provider Name (Legal Business Name): KIMBERLY MEADE SHELL RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 HOLLY AVE
LOGAN WV
25601-3306
US

IV. Provider business mailing address

506 HOLLY AVE
LOGAN WV
25601-3306
US

V. Phone/Fax

Practice location:
  • Phone: 304-752-1804
  • Fax: 304-852-0207
Mailing address:
  • Phone: 304-752-1804
  • Fax: 304-752-0207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number47114
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: