Provider Demographics
NPI:1639143837
Name:SHELLHOUSE, MARY E (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:SHELLHOUSE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P O BOX 640
Mailing Address - Street 2:115 MEDICAL PARK DRIVE
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420
Mailing Address - Country:US
Mailing Address - Phone:334-222-5781
Mailing Address - Fax:334-222-5794
Practice Address - Street 1:115 MEDICAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420
Practice Address - Country:US
Practice Address - Phone:334-222-5781
Practice Address - Fax:334-222-5794
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-097517163WG0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL891010000Medicaid
AL051555990Medicare ID - Type Unspecified
Q44244Medicare UPIN
AL891010000Medicaid