Provider Demographics
NPI:1093280349
Name:SHELLY, CHRISTIE DELORIS (NP)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:DELORIS
Last Name:SHELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-4117
Mailing Address - Country:US
Mailing Address - Phone:715-483-3261
Mailing Address - Fax:715-483-0507
Practice Address - Street 1:235 E STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-4117
Practice Address - Country:US
Practice Address - Phone:715-483-3261
Practice Address - Fax:715-483-0507
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAG10180092363LG0600X
WI12000-33363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology