Provider Demographics
NPI:1275615593
Name:BREYEN, SHELLY A (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:A
Last Name:BREYEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1164
Mailing Address - Country:US
Mailing Address - Phone:218-879-1271
Mailing Address - Fax:218-879-8904
Practice Address - Street 1:417 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1164
Practice Address - Country:US
Practice Address - Phone:218-879-1271
Practice Address - Fax:218-879-8904
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN073027100Medicaid
MN6D235BROtherBLUES & FIRST PLAN
MN0102361OtherMEDICA
MN089005571Medicare ID - Type Unspecified
MN6D235BROtherBLUES & FIRST PLAN