Basic Information
| Provider Information | |||||||||
| NPI: | 1629028477 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHULL-DIENER | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | MAE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4640 W ALEXIS RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436231006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198438150 | ||||||||
| FaxNumber: | 4194792579 | ||||||||
| Practice Location | |||||||||
| Address1: | 4640 W ALEXIS RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436231006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198438150 | ||||||||
| FaxNumber: | 4194792579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP08368 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 000000475788 | 01 | OH | ANTHEM | OTHER | 2614559 | 05 | OH | MEDICAID | P00301721 | 01 | OH | RRMC | OTHER | PENDING | 01 | OH | ANTHEM | OTHER |