Provider Demographics
NPI:1609203884
Name:SHERRELL, SHANTANIECE (NP)
Entity Type:Individual
Prefix:
First Name:SHANTANIECE
Middle Name:
Last Name:SHERRELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 RONALD REAGAN PKWY STE B1500
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7085
Mailing Address - Country:US
Mailing Address - Phone:317-217-2244
Mailing Address - Fax:
Practice Address - Street 1:1111 RONALD REAGAN PKWY STE B1500
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7085
Practice Address - Country:US
Practice Address - Phone:317-217-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28172966A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201199910Medicaid
INP01291681OtherRAILROAD MEDICARE
INP01291681OtherRAILROAD MEDICARE