Provider Demographics
NPI:1528499001
Name:KELLY-WICKERSHEIM, SHAWNA (CPM)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:KELLY-WICKERSHEIM
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 NE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-2014
Mailing Address - Country:US
Mailing Address - Phone:541-550-6200
Mailing Address - Fax:541-447-4118
Practice Address - Street 1:591 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-2014
Practice Address - Country:US
Practice Address - Phone:541-550-6200
Practice Address - Fax:541-447-4118
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife