Provider Demographics
NPI:1285695775
Name:SHIRLEY, REBECCA JO (CNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JO
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 S SHOOP AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1702
Mailing Address - Country:US
Mailing Address - Phone:419-330-2772
Mailing Address - Fax:419-330-2771
Practice Address - Street 1:725 S SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1702
Practice Address - Country:US
Practice Address - Phone:419-330-2772
Practice Address - Fax:419-330-2771
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-04761363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner