Provider Demographics
NPI:1003872623
Name:MCINTOSH, SHELLY J (FNP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:J
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E SPRINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1761
Mailing Address - Country:US
Mailing Address - Phone:423-794-5520
Mailing Address - Fax:423-282-6940
Practice Address - Street 1:301 MED TECH PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2364
Practice Address - Country:US
Practice Address - Phone:423-794-5520
Practice Address - Fax:423-282-0720
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN127044363LF0000X
TNAPN12000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3643640Medicaid
TNQ007095Medicaid
TN3643640Medicare PIN