Provider Demographics
NPI:1093722613
Name:BOONE, SHELLY S (NP)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:S
Last Name:BOONE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:S
Other - Last Name:DAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:
Practice Address - Street 1:1025 MACHESTER AVE
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1496
Practice Address - Country:US
Practice Address - Phone:260-563-7421
Practice Address - Fax:260-563-7725
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28144111A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN21358OtherPHP
IN200842600Medicaid
IN000000504327OtherBCBS
INQ77430Medicare UPIN
IN000000504327OtherBCBS