Provider Demographics
NPI:1114106184
Name:BUCH, SHELLY RAE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:RAE
Last Name:BUCH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:SHELLY
Other - Middle Name:RAE
Other - Last Name:SCHINTGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-0549
Mailing Address - Country:US
Mailing Address - Phone:906-774-1313
Mailing Address - Fax:
Practice Address - Street 1:1010 OLIVE AVE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:WI
Practice Address - Zip Code:54121-0380
Practice Address - Country:US
Practice Address - Phone:715-528-4775
Practice Address - Fax:715-528-5592
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1084363LF0000X
WI4575-033363LF0000X
MI4704222854363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP0063Medicaid