1093722613 NPI number — MRS. SHELLY S BOONE NP

Table of content: MRS. SHELLY S BOONE NP (NPI 1093722613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093722613 NPI number — MRS. SHELLY S BOONE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOONE
Provider First Name:
SHELLY
Provider Middle Name:
S
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAWSON
Provider Other First Name:
SHELLY
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
R.N.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093722613
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11109 PARKVIEW PLAZA DR # 117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-266-6013
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 MACHESTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WABASH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46992-1496
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-563-7421
Provider Business Practice Location Address Fax Number:
260-563-7725
Provider Enumeration Date:
08/03/2006

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: 363L00000X , with the licence number:  28144111A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 21358 . This is a "PHP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200842600 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000504327 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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