Provider Demographics
NPI:1083969240
Name:SHELLEY, LATINA D (APRN, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:LATINA
Middle Name:D
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:APRN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 S ELM PL STE 106
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5369
Mailing Address - Country:US
Mailing Address - Phone:918-928-5437
Mailing Address - Fax:888-720-8944
Practice Address - Street 1:817 S ELM PL STE 106
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5369
Practice Address - Country:US
Practice Address - Phone:918-928-5437
Practice Address - Fax:888-720-8944
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0106308208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics