Provider Demographics
NPI:1447885033
Name:RYALS, SHELLY TIARA
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:TIARA
Last Name:RYALS
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 1:1142 DELOS ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44306-2425
Mailing Address - Country:US
Mailing Address - Phone:330-801-9571
Mailing Address - Fax:
Practice Address - Street 1:1142 DELOS ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44306-2425
Practice Address - Country:US
Practice Address - Phone:330-801-9571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRQ347281Medicaid
OHRQ347281OtherOHIO IDENTIFICATION CARD