Provider Demographics
NPI:1578030334
Name:DEWITT, SHELBY (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:DEWITT
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 STONEWOOD DR # 2
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9696
Mailing Address - Country:US
Mailing Address - Phone:616-886-6921
Mailing Address - Fax:
Practice Address - Street 1:966 STONEWOOD DR # 2
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49456-9696
Practice Address - Country:US
Practice Address - Phone:616-886-6921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704249824363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care