Provider Demographics
NPI:1750643664
Name:KOHL, SHELLEY MARIE (CPCP CERT)
Entity type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:MARIE
Last Name:KOHL
Suffix:
Gender:F
Credentials:CPCP CERT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E CENTER ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4727
Mailing Address - Country:US
Mailing Address - Phone:209-456-7056
Mailing Address - Fax:209-239-3033
Practice Address - Street 1:425 E. CENTER ST SUITE 1
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336
Practice Address - Country:US
Practice Address - Phone:209-456-7056
Practice Address - Fax:209-239-3033
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical