MEDICARE: LYEA DORAE SHINE

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	163W00000X	Registered Nurse	2014029095	MO
2	367500000X	Certified Registered Nurse Anesthetist	811313	NY

General Provider Information

NPI Number	:	1396346870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYEA DORAE SHINE

Provider Business Mailing Address
First Line	:	PO BOX 68
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-0068
Country	:	US
Telephone Number	:	904-254-3686
Fax Number	:

Provider Business Practice Location Address
First Line	:	502 MCCURRY ST
Second Line	:
City	:	PLEASANT HOPE
State	:	MO
Zip	:	65725-9231
Country	:	US
Telephone Number	:	904-254-3686
Fax Number	:

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

Provider Enumeration Date	:	11/03/2020
Last Update Date	:	06/01/2021

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Directions to “ LYEA DORAE SHINE ” Practice Location

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