Provider Demographics
NPI:1316601909
Name:BACH, SHELBY (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:BACH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CARPENTERS GRADE RD
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-2618
Mailing Address - Country:US
Mailing Address - Phone:865-292-3855
Mailing Address - Fax:
Practice Address - Street 1:2925 CARPENTERS GRADE RD
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-2618
Practice Address - Country:US
Practice Address - Phone:865-292-3855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN224204163WN0002X
TN30481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive CareGroup - Single Specialty