Provider Demographics
NPI:1477162469
Name:SHELLHOUSE, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:SHELLHOUSE
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 1:4035 E STONY MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85756-3076
Mailing Address - Country:US
Mailing Address - Phone:520-870-0733
Mailing Address - Fax:
Practice Address - Street 1:4035 E STONY MEADOW DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85756-3076
Practice Address - Country:US
Practice Address - Phone:520-870-0733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH6304385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH6304OtherAZ DEPT OF HEALTH SERVICES