Provider Demographics
NPI:1598710584
Name:NANDA, SHELLY (MD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:NANDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MERCY DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-3128
Mailing Address - Country:US
Mailing Address - Phone:712-388-2770
Mailing Address - Fax:
Practice Address - Street 1:800 MERCY DR
Practice Address - Street 2:SUITE 120
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-3128
Practice Address - Country:US
Practice Address - Phone:712-388-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36557207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0727099Medicaid
NE10025393600Medicaid
IAI17789Medicare ID - Type Unspecified
IAI55802Medicare UPIN