1588696413 NPI number — SHELLY M SCHUTTE P-AC

Table of content: SHELLY M SCHUTTE P-AC (NPI 1588696413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588696413 NPI number — SHELLY M SCHUTTE P-AC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHUTTE
Provider First Name:
SHELLY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P-AC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1588696413
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 S 169TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68118-9300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-354-5677
Provider Business Mailing Address Fax Number:
402-354-5454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7831 CHICAGO CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68114-3654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-354-1230
Provider Business Practice Location Address Fax Number:
402-354-5621
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  075825 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 878 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 37753 . This is a "BCBSNE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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