Provider Demographics
NPI:1134517238
Name:BOUIE, SHELLY LAUREN (RN)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:LAUREN
Last Name:BOUIE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:SHELLY
Other - Middle Name:LAUREN
Other - Last Name:BOUIE-RUTLEDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:308 CHALMERS ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-3162
Mailing Address - Country:US
Mailing Address - Phone:313-409-5006
Mailing Address - Fax:
Practice Address - Street 1:308 CHALMERS ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-3162
Practice Address - Country:US
Practice Address - Phone:313-409-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-26
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704241563163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse