Provider Demographics
NPI:1235915521
Name:WHITE, SHELLY J
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:J
Last Name:WHITE
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 1:6704 JACOBS WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-3254
Mailing Address - Country:US
Mailing Address - Phone:608-576-1573
Mailing Address - Fax:
Practice Address - Street 1:6704 JACOBS WAY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-3254
Practice Address - Country:US
Practice Address - Phone:608-576-1573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9735-16124Q00000X
WI177798-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No124Q00000XDental ProvidersDental Hygienist