Provider Demographics
NPI:1386229037
Name:RENEE, SHELLEY (CNM)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:RENEE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 GLEN OAKS AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3036
Mailing Address - Country:US
Mailing Address - Phone:651-776-2369
Mailing Address - Fax:
Practice Address - Street 1:3100 GLEN OAKS AVE STE 107
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3036
Practice Address - Country:US
Practice Address - Phone:651-776-2369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty