Provider Demographics
NPI:1073590428
Name:LANDRY, SHELLEY M (M PA C)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:M
Last Name:LANDRY
Suffix:
Gender:F
Credentials:M PA C
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:M
Other - Last Name:DUQUETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:789 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2526
Mailing Address - Country:US
Mailing Address - Phone:603-609-6819
Mailing Address - Fax:603-609-6821
Practice Address - Street 1:789 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2526
Practice Address - Country:US
Practice Address - Phone:603-609-6819
Practice Address - Fax:603-609-6821
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3071730Medicaid
NHAP2343Medicare ID - Type Unspecified