Basic Information
| Provider Information | |||||||||
| NPI: | 1093280349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELLY | ||||||||
| FirstName: | CHRISTIE | ||||||||
| MiddleName: | DELORIS | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540244117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833261 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540244117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833261 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2018 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | AG10180092 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LG0600X | 12000-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.