Provider Demographics
NPI:1972703585
Name:MEDLEY, SHAWYNE M
Entity type:Individual
Prefix:MS
First Name:SHAWYNE
Middle Name:M
Last Name:MEDLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 BROMTON CT
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-5426
Mailing Address - Country:US
Mailing Address - Phone:614-563-3656
Mailing Address - Fax:
Practice Address - Street 1:4200 BROMTON CT
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-5426
Practice Address - Country:US
Practice Address - Phone:614-563-3656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-21
Last Update Date:2007-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK374U00000X374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2200166Medicaid