Provider Demographics
NPI:1003540097
Name:PRESTON, SHYLEE SUE
Entity Type:Individual
Prefix:MRS
First Name:SHYLEE
Middle Name:SUE
Last Name:PRESTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5449 RICE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-9407
Mailing Address - Country:US
Mailing Address - Phone:218-393-3364
Mailing Address - Fax:
Practice Address - Street 1:407 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1950
Practice Address - Country:US
Practice Address - Phone:218-786-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR203078-0163W00000X
WI250903-30163W00000X
MN143923367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty