Provider Demographics
NPI:1871753368
Name:SHELL, KIMBERLY MEADE (RN, BSN)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MEADE
Last Name:SHELL
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3306
Mailing Address - Country:US
Mailing Address - Phone:304-752-1804
Mailing Address - Fax:304-752-0207
Practice Address - Street 1:506 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3306
Practice Address - Country:US
Practice Address - Phone:304-752-1804
Practice Address - Fax:304-852-0207
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV47114163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0060164000Medicaid