Provider Demographics
NPI:1598720534
Name:SHUCK, KELLIE L (PMHNP-CNS, BC)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:L
Last Name:SHUCK
Suffix:
Gender:F
Credentials:PMHNP-CNS, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W 7TH ST STE 900
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-3013
Mailing Address - Country:US
Mailing Address - Phone:888-285-2269
Mailing Address - Fax:888-285-2269
Practice Address - Street 1:30 HOULTON ST
Practice Address - Street 2:
Practice Address - City:PATTEN
Practice Address - State:ME
Practice Address - Zip Code:04765-3035
Practice Address - Country:US
Practice Address - Phone:866-366-5842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000161947364SP0808X
MECNP211623363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427531801Medicaid
MO427531801Medicaid
MA1200Medicare PIN
MO152360667Medicare PIN