MEDICARE: MRS. SHELLY ROSE WILKES LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	2014024802	MO

General Provider Information

NPI Number	:	1043682453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHELLY ROSE WILKES LPN

Provider Business Mailing Address
First Line	:	3103 PARHAM DR APT 227
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-7726
Country	:	US
Telephone Number	:	817-495-4880
Fax Number	:	214-235-0789

Provider Business Practice Location Address
First Line	:	3103 PARHAM DR APT 227
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-7726
Country	:	US
Telephone Number	:	817-495-4880
Fax Number	:	214-235-0789

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2015
Last Update Date	:	10/24/2015

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