Provider Demographics
NPI:1629043849
Name:GUDEHUS, SHELLY L (FNP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:GUDEHUS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5227
Mailing Address - Country:US
Mailing Address - Phone:573-632-5580
Mailing Address - Fax:573-632-5876
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5580
Practice Address - Fax:573-632-5876
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000687363LF0000X
MO133429363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO133429OtherMO LICENSE
ILRN LICENSEOther041319304
S82507Medicare UPIN