MEDICARE: SHAWN LEE MCKIDDY

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1851055867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWN LEE MCKIDDY

Provider Business Mailing Address
First Line	:	542 OLD WILKES RD
Second Line	:
City	:	GLENDALE SPRINGS
State	:	NC
Zip	:	28629-9103
Country	:	US
Telephone Number	:	336-977-0290
Fax Number	:

Provider Business Practice Location Address
First Line	:	542 OLD WILKES RD
Second Line	:
City	:	GLENDALE SPRINGS
State	:	NC
Zip	:	28629-9103
Country	:	US
Telephone Number	:	336-977-0290
Fax Number	:

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

Provider Enumeration Date	:	10/26/2021
Last Update Date	:	10/26/2021

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Directions to “ SHAWN LEE MCKIDDY ” Practice Location

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