Healthcare Provider Details

I. General information

NPI: 1275447427
Provider Name (Legal Business Name): SHELISE OTT HENDERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELISE OTT RN

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 CASPIAN WAY
SHENANDOAH JUNCTION WV
25442-4804
US

IV. Provider business mailing address

75 CASPIAN WAY
SHENANDOAH JUNCTION WV
25442-4804
US

V. Phone/Fax

Practice location:
  • Phone: 304-885-5020
  • Fax:
Mailing address:
  • Phone: 304-885-5020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number82109
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: