Provider Demographics
NPI:1093083032
Name:SHELLY, ANDRE L
Entity Type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:L
Last Name:SHELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BRANDYWINE BLVD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-6156
Mailing Address - Country:US
Mailing Address - Phone:404-798-6741
Mailing Address - Fax:
Practice Address - Street 1:301 BRANDYWINE BLVD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-6156
Practice Address - Country:US
Practice Address - Phone:404-798-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies