Provider Demographics
NPI:1538768486
Name:ENTLER, SHELLY
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:ENTLER
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:PO BOX 495
Mailing Address - Street 2:
Mailing Address - City:FELICITY
Mailing Address - State:OH
Mailing Address - Zip Code:45120-0495
Mailing Address - Country:US
Mailing Address - Phone:740-222-1731
Mailing Address - Fax:
Practice Address - Street 1:19448 STATE ROUTE 772
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-8910
Practice Address - Country:US
Practice Address - Phone:740-222-1731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH584778848Medicaid