Provider Demographics
NPI:1578576807
Name:WILLHAM, SHELLY E (CFNP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:E
Last Name:WILLHAM
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:REEDY
Mailing Address - State:WV
Mailing Address - Zip Code:25270-9367
Mailing Address - Country:US
Mailing Address - Phone:304-372-2731
Mailing Address - Fax:304-372-2749
Practice Address - Street 1:122 PINNELL STREET
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:WV
Practice Address - Zip Code:25271
Practice Address - Country:US
Practice Address - Phone:304-372-2731
Practice Address - Fax:304-372-2749
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV57551363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVQ72168Medicare UPIN
WV513410Medicare Oscar/Certification
WV21871Medicare PIN