1790848364 NPI number — SANDRA D SHELLEY CRNA

Table of content: SANDRA D SHELLEY CRNA (NPI 1790848364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790848364 NPI number — SANDRA D SHELLEY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHELLEY
Provider First Name:
SANDRA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1790848364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4509 WOODLAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29582-5244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3911 HIGHWAY 17 # B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRELLS INLET
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29576-5014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-651-8211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2006

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: 367500000X , with the licence number:  18465 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00395317 . This is a "RR MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 204185222 . This is a "BCBS OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 204185222 . This is a "TRICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: GP4376 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: AN0060 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE5998 . This is a "RR MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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