Provider Demographics
NPI:1407349780
Name:PAULSON, SHELLY RENEE
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RENEE
Last Name:PAULSON
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 1:7742 PENNOVER CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-7170
Mailing Address - Country:US
Mailing Address - Phone:317-696-0165
Mailing Address - Fax:
Practice Address - Street 1:6100 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2452
Practice Address - Country:US
Practice Address - Phone:317-296-4914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator