Provider Demographics
NPI:1164925863
Name:HIPPS, SHELTANA MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:SHELTANA
Middle Name:MICHELLE
Last Name:HIPPS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 BERNARDIN AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2044
Mailing Address - Country:US
Mailing Address - Phone:803-409-7170
Mailing Address - Fax:803-409-7175
Practice Address - Street 1:2435 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2026
Practice Address - Country:US
Practice Address - Phone:803-409-7170
Practice Address - Fax:803-409-7175
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21620363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC21620OtherMEDICAL LICENSE