Provider Demographics
NPI:1194073031
Name:MINOR, SHIRLEY DENISE
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:DENISE
Last Name:MINOR
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SHIRLEY
Other - Middle Name:DENISE
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1452 MENLO LOOP
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-7678
Mailing Address - Country:US
Mailing Address - Phone:541-221-4099
Mailing Address - Fax:
Practice Address - Street 1:1452 MENLO LOOP
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7678
Practice Address - Country:US
Practice Address - Phone:541-221-4099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201130551LPN164W00000X
IN16030164W00000X
CAVN112467164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse