Provider Demographics
NPI:1326524216
Name:ANDERSON, SHELLEY DEEANN
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:DEEANN
Last Name:ANDERSON
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 1:1805 S SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003
Mailing Address - Country:US
Mailing Address - Phone:918-350-8463
Mailing Address - Fax:
Practice Address - Street 1:504 S. CHEROKEE AVE.
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003
Practice Address - Country:US
Practice Address - Phone:918-876-4046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-14
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$Medicaid