Provider Demographics
NPI:1194268664
Name:RADER, SHELBY NICOLE
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:NICOLE
Last Name:RADER
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 1:2204 BRESSLER DR
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1506
Mailing Address - Country:US
Mailing Address - Phone:610-741-7756
Mailing Address - Fax:
Practice Address - Street 1:123 GOLD ST
Practice Address - Street 2:
Practice Address - City:SHILLINGTON
Practice Address - State:PA
Practice Address - Zip Code:19607-1119
Practice Address - Country:US
Practice Address - Phone:610-741-7756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0069852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer