Provider Demographics
NPI:1003284027
Name:BERTRAM, SHELLY (RN)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9261 W VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-2941
Mailing Address - Country:US
Mailing Address - Phone:623-936-9740
Mailing Address - Fax:
Practice Address - Street 1:9261 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-2941
Practice Address - Country:US
Practice Address - Phone:623-936-9740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN097015163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool