1073585493 NPI number — MRS. SHELLY LYNN CLYDE R.D, L.D

Table of content: MRS. SHELLY LYNN CLYDE R.D, L.D (NPI 1073585493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073585493 NPI number — MRS. SHELLY LYNN CLYDE R.D, L.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLYDE
Provider First Name:
SHELLY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
R.D, L.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073585493
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HHC 121 GENERAL HOSPITAL
Provider Second Line Business Mailing Address:
BOX 663
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
01182279175302
Provider Business Mailing Address Fax Number:
01182279173251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HHC 121 GENERAL HOSPITAL
Provider Second Line Business Practice Location Address:
BOX 663
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
01182279175302
Provider Business Practice Location Address Fax Number:
01182279173251
Provider Enumeration Date:
02/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  DT06316 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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