1245594563 NPI number — SHELBY ELIZABETH BRYAN LVN, TS-C, FA

Table of content: SHELBY ELIZABETH BRYAN LVN, TS-C, FA (NPI 1245594563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245594563 NPI number — SHELBY ELIZABETH BRYAN LVN, TS-C, FA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYAN
Provider First Name:
SHELBY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LVN, TS-C, FA
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:
1245594563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
664 BILLY CLARK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75949-2917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-630-8822
Provider Business Mailing Address Fax Number:
936-634-1862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 GASLIGHT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUFKIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75904-3166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-630-8822
Provider Business Practice Location Address Fax Number:
936-634-8836
Provider Enumeration Date:
07/02/2012

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: 246ZC0007X , 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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