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General NPI Number Information
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NPI Number | 1396346870
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Entity Type | Individual
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Provider Name | LYEA DORAE SHINE
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Gender | Female
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Dates
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Enumeration Date | 11/03/2020
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Last Update Date | 06/01/2021
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Provider Practice Location Address
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Address Line | 502 MCCURRY ST
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City | PLEASANT HOPE
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State | MO
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Zip | 65725-9231
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Country | US
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Telephone | 904-254-3686
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 68
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City | FAYETTEVILLE
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State | NY
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Zip | 13066-0068
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Country | US
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Telephone | 904-254-3686
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 2014029095
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 811313
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License Number State | NY
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