Provider Demographics
NPI:1063129096
Name:FLEMING, SHELLY KAY (PTA)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:KAY
Last Name:FLEMING
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 WOLLENHAUPT DR
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-3266
Mailing Address - Country:US
Mailing Address - Phone:937-329-0873
Mailing Address - Fax:
Practice Address - Street 1:1076 WOLLENHAUPT DR
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-3266
Practice Address - Country:US
Practice Address - Phone:937-329-0873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02575225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRT269951OtherDRIVERS LICENSE