Provider Demographics
NPI:1104382597
Name:SHUPTRINE, AMY JO (MSN, APRN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JO
Last Name:SHUPTRINE
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14280 STATE HIGHWAY 155
Mailing Address - Street 2:
Mailing Address - City:FRANKSTON
Mailing Address - State:TX
Mailing Address - Zip Code:75763-6734
Mailing Address - Country:US
Mailing Address - Phone:903-574-2612
Mailing Address - Fax:
Practice Address - Street 1:2000 S PALESTINE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-5610
Practice Address - Country:US
Practice Address - Phone:903-676-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX812655207PE0004X
TXAP140582363LA2100X, 363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15390359OtherTEXAS DRIVERS LICENSE