Provider Demographics
NPI:1285302968
Name:VINCENT, SHELBY LYNNE (PTA)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LYNNE
Last Name:VINCENT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-4948
Mailing Address - Country:US
Mailing Address - Phone:302-734-1515
Mailing Address - Fax:
Practice Address - Street 1:313 S 5TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:DE
Practice Address - Zip Code:19730-2078
Practice Address - Country:US
Practice Address - Phone:302-376-4128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0001176225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant