Provider Demographics
NPI:1346639283
Name:ANDERSON, SHELLY DAWN (DNP APRN, CNP)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:DAWN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DNP APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 N BROADWAY ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2538
Mailing Address - Country:US
Mailing Address - Phone:918-385-1544
Mailing Address - Fax:918-635-3308
Practice Address - Street 1:2104 N BROADWAY ST
Practice Address - Street 2:UNIT A
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2538
Practice Address - Country:US
Practice Address - Phone:918-564-2726
Practice Address - Fax:918-564-2732
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK88955363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200571200Medicaid