Provider Demographics
NPI:1063491405
Name:GRESHAM, SHELLY Y (RNC-FNP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:Y
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:RNC-FNP
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:Y
Other - Last Name:BEARDSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2480 THREE RIVERS BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2318
Mailing Address - Country:US
Mailing Address - Phone:573-686-5564
Mailing Address - Fax:573-686-2838
Practice Address - Street 1:2480 THREE RIVERS BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2318
Practice Address - Country:US
Practice Address - Phone:573-686-5564
Practice Address - Fax:573-686-2838
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO126637363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428569842Medicaid
MO428569842Medicaid
MO817734039Medicare PIN