Provider Demographics
NPI:1245797547
Name:CALLAHAN, SHELLY DENISE (LAC)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:DENISE
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E LOST HILLS ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-8775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:614 N MULBERRY RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3532
Practice Address - Country:US
Practice Address - Phone:316-305-3958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-23
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS23-00012171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist