Provider Demographics
NPI:1104041235
Name:SHELTON, JANINEA (RN)
Entity Type:Individual
Prefix:MS
First Name:JANINEA
Middle Name:
Last Name:SHELTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E NIZHONI BLVD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5748
Mailing Address - Country:US
Mailing Address - Phone:505-722-1790
Mailing Address - Fax:
Practice Address - Street 1:3418 GRACE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-4711
Practice Address - Country:US
Practice Address - Phone:636-527-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012038045163W00000X
MO20060098211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002101Medicaid
2875271Medicare ID - Type Unspecified