Provider Demographics
NPI:1215537428
Name:CROSS, SHELLY
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:CROSS
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 1:169 BRENTON DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-3470
Mailing Address - Country:US
Mailing Address - Phone:740-975-7890
Mailing Address - Fax:
Practice Address - Street 1:169 BRENTON DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-3470
Practice Address - Country:US
Practice Address - Phone:740-975-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker