Provider Demographics
NPI:1407254808
Name:REAVES, SHELLEY NICOLE (APN)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:NICOLE
Last Name:REAVES
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 BEND RD
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-8600
Mailing Address - Country:US
Mailing Address - Phone:731-445-0127
Mailing Address - Fax:731-723-1302
Practice Address - Street 1:9159 TELECOM DR
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358
Practice Address - Country:US
Practice Address - Phone:731-686-4212
Practice Address - Fax:731-723-1302
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2018-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN161142163W00000X
TN19505363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse