Provider Demographics
NPI:1083679104
Name:SHELTON, OMA L (CFNP)
Entity Type:Individual
Prefix:
First Name:OMA
Middle Name:L
Last Name:SHELTON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:OMA
Other - Middle Name:L
Other - Last Name:NOLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:P.O. BOX 939
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-0939
Mailing Address - Country:US
Mailing Address - Phone:417-777-4800
Mailing Address - Fax:
Practice Address - Street 1:2230 S SPRINGFIELD AVE
Practice Address - Street 2:SUITE H-J
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-9133
Practice Address - Country:US
Practice Address - Phone:417-777-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO080074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1083679104Medicaid
MO138880069Medicare PIN