1275147266 NPI number — SHELLEY ANN SHAFFER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275147266 NPI number — SHELLEY ANN SHAFFER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELLEY ANN SHAFFER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHAFFER PROFESSIONAL SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275147266
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 463
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOOSE LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55767-0463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-380-0175
Provider Business Mailing Address Fax Number:
218-485-9105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 ARROWHEAD LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOOSE LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55767-7707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-380-0175
Provider Business Practice Location Address Fax Number:
218-485-9105
Provider Enumeration Date:
09/07/2020

Additional Information

Authorized Official

Authorized Official Last Name:
SHAFFER
Authorized Official First Name:
SHELLEY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
218-380-0175

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1275147266 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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