1154379899 NPI number — CHRISTINA MARIE SHEELY D.O.

Table of content: CHRISTINA MARIE SHEELY D.O. (NPI 1154379899)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154379899 NPI number — CHRISTINA MARIE SHEELY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEELY
Provider First Name:
CHRISTINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAIGREPONT
Provider Other First Name:
CHRISTINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154379899
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1180 SETON PKWY
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
KYLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78640-6178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-504-0076
Provider Business Mailing Address Fax Number:
512-504-0075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1180 SETON PKWY
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
KYLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78640-6178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-504-0086
Provider Business Practice Location Address Fax Number:
888-213-8128
Provider Enumeration Date:
05/05/2006

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: 207X00000X , with the licence number:  L5533 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: 5101015949 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 204301006 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 204301005 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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