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General NPI Number Information
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NPI Number | 1518584259
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Entity Type | Individual
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Provider Name | SHELBY L BLACKLEY
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Gender | Female
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Dates
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Enumeration Date | 06/29/2020
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Last Update Date | 10/01/2025
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Provider Practice Location Address
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Address Line | 5520 PARK AVE STE WP-2300
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City | TRUMBULL
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State | CT
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Zip | 06611-3463
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Country | US
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Telephone | 203-374-0310
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Fax |
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Provider Business Mailing Address
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Address Line | 60 METROPOLITAN PARK DR
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City | RIVERSIDE
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State | RI
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Zip | 02915-2150
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Country | US
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Telephone | 508-463-7929
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 4908
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License Number State | CT
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