Provider Demographics
NPI:1578021374
Name:MOLLENKAMP, SHELBY TANNER (CRNA)
Entity Type:Individual
Prefix:MR
First Name:SHELBY
Middle Name:TANNER
Last Name:MOLLENKAMP
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 E PIANKISHAW ST
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-1717
Mailing Address - Country:US
Mailing Address - Phone:785-754-8265
Mailing Address - Fax:
Practice Address - Street 1:1500 SW 10TH AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-1301
Practice Address - Country:US
Practice Address - Phone:785-354-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-120438-042163W00000X
KS557708367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse