Provider Demographics
NPI:1487328860
Name:HARRIS, SHELLY (RN)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8597 BALCOM CROSS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTON
Mailing Address - State:NY
Mailing Address - Zip Code:14138-9610
Mailing Address - Country:US
Mailing Address - Phone:716-785-0448
Mailing Address - Fax:
Practice Address - Street 1:42 LAKE ST STE D
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-4937
Practice Address - Country:US
Practice Address - Phone:716-410-5390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY686945163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse