Provider Demographics
NPI:1538876602
Name:WHITEHEAD, SHELLY MARIE (LVN)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5830 STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5621
Mailing Address - Country:US
Mailing Address - Phone:254-265-3530
Mailing Address - Fax:
Practice Address - Street 1:3015 HERRING AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3238
Practice Address - Country:US
Practice Address - Phone:888-236-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311522164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX311522OtherTEXAS BOARD OF NURSING