Provider Demographics
NPI:1629055736
Name:CHANDLER, SHELLY (NP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:CHANDLER
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 1:1290 SILAS DEANE HWY
Mailing Address - Street 2:HARTFORD HEALTHCARE-CVO
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:199 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3501
Practice Address - Country:US
Practice Address - Phone:203-874-2543
Practice Address - Fax:203-874-2544
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254081363L00000X
KY3007254363LF0000X
MO2012029067363LF0000X
CT12.007315363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP4179OtherBLUE CROSS BLUE SHIELD
MAP89457Medicare UPIN
MANP4179Medicare ID - Type Unspecified