1881998128 NPI number — GWENDOLYN SHELLY R.D.

Table of content: GWENDOLYN SHELLY R.D. (NPI 1881998128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881998128 NPI number — GWENDOLYN SHELLY R.D.

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NISSLEY
Provider Other First Name:
GWENDOLYN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881998128
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 N WATER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17603-3374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-299-6372
Provider Business Mailing Address Fax Number:
717-325-8057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6692 MIDDLE RD
Provider Second Line Business Practice Location Address:
SUITE 2100
Provider Business Practice Location Address City Name:
SODUS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14551-9602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-483-1199
Provider Business Practice Location Address Fax Number:
315-483-2451
Provider Enumeration Date:
12/30/2010

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:  000747-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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