Basic Information
| Provider Information | |||||||||
| NPI: | 1285791467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARNEY | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C,MPAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL STE 550 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453426115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377621310 | ||||||||
| FaxNumber: | 9375228068 | ||||||||
| Practice Location | |||||||||
| Address1: | 450B WASHINGTON JACKSON RD STE 108 | ||||||||
| Address2: | |||||||||
| City: | EATON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453207601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374568330 | ||||||||
| FaxNumber: | 9374568335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 50.001597 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 50.001597RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1046561 | 01 | NATIONAL CERTIFICATION NU | OTHER | 50.001597 | 01 | OH | P.A. REGISTRATION NUMBER | OTHER | 41-3208 | 01 | OH | OHIO SUPERVISORY AGREEMEN | OTHER |