Provider Demographics
NPI:1124506969
Name:MERRIETT, SHELBY RAE
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:RAE
Last Name:MERRIETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 S SERVICE RD APT 931
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-5571
Mailing Address - Country:US
Mailing Address - Phone:318-366-4082
Mailing Address - Fax:
Practice Address - Street 1:1414 SW 89TH ST STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6312
Practice Address - Country:US
Practice Address - Phone:405-703-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1988224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant