Provider Demographics
NPI:1841699295
Name:SHEALEY-MARINE, TONIA (LPN)
Entity type:Individual
Prefix:
First Name:TONIA
Middle Name:
Last Name:SHEALEY-MARINE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TONIA
Other - Middle Name:LYNN
Other - Last Name:MARINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:120 ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-3162
Mailing Address - Country:US
Mailing Address - Phone:313-779-2857
Mailing Address - Fax:
Practice Address - Street 1:120 ROSE WAY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-3162
Practice Address - Country:US
Practice Address - Phone:313-779-2857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN087067164W00000X
TX217206164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse