Provider Demographics
NPI:1538631692
Name:SHOCKLEY, NICOLE SKYE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SKYE
Last Name:SHOCKLEY
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 1:629 NW CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-5202
Mailing Address - Country:US
Mailing Address - Phone:971-716-6268
Mailing Address - Fax:
Practice Address - Street 1:625 NE GALLOWAY ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-3933
Practice Address - Country:US
Practice Address - Phone:503-434-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist