Provider Demographics
NPI:1104971506
Name:CLANTON, SHELLY ANN (OD)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:CLANTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6321 N 51ST PL
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-4134
Mailing Address - Country:US
Mailing Address - Phone:602-808-8686
Mailing Address - Fax:
Practice Address - Street 1:1425 W SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4814
Practice Address - Country:US
Practice Address - Phone:480-833-6786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist