Provider Demographics
NPI:1821885070
Name:SHINE, ALEXIS (PRSS)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:SHINE
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-8804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 TWIN KNOBS
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-2742
Practice Address - Country:US
Practice Address - Phone:681-285-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25-944SUD175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist