Provider Demographics
NPI:1407088727
Name:SHELLEM, VICTORIA J (CRNP)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:J
Last Name:SHELLEM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6573
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2000 MEDICAL PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3742
Practice Address - Country:US
Practice Address - Phone:443-481-5300
Practice Address - Fax:443-481-6705
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR153442363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD025825300Medicaid
DCV8740009OtherBCBS
MD169723ZCU2OtherMEDICARE GROUP MEMBER PTAN
MD95586303OtherBCBS MD
DCV8380009OtherBCBS
MD95586304OtherBCBS
MD95586305OtherBCBS
DCV8080009OtherBCBS
MD9284514OtherAETNA PPO
MD11995694OtherCOUNCIL FOR AFFORDABLE QUALITY HEALTHCARE
MD8057972OtherAETNA HMO
DCV8380009OtherBCBS
MD169723ZCU2OtherMEDICARE GROUP MEMBER PTAN
MD025825300Medicaid