Provider Demographics
NPI:1114919818
Name:DIEHL, SHELLEY BRINKMAN
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:BRINKMAN
Last Name:DIEHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 DUFF AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-5469
Mailing Address - Country:US
Mailing Address - Phone:515-239-4400
Mailing Address - Fax:
Practice Address - Street 1:1215 DUFF AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-5469
Practice Address - Country:US
Practice Address - Phone:515-239-4432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00016019OtherRR MEDICARE
S98527Medicare UPIN
IA415300012Medicare PIN
IAP00016019OtherRR MEDICARE