Provider Demographics
NPI:1558408443
Name:SHELTON, CAROL A (CRNA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:SHELTON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30200 TELEGRAPH RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4502
Mailing Address - Country:US
Mailing Address - Phone:248-258-5058
Mailing Address - Fax:
Practice Address - Street 1:4550 INVESTMENT DR
Practice Address - Street 2:SUITE 100
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-6363
Practice Address - Country:US
Practice Address - Phone:248-265-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704140166367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4708032Medicaid
MI0N88130024Medicare ID - Type Unspecified