Provider Demographics
NPI:1639145550
Name:NIELSON, SHELLEY L (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:L
Last Name:NIELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-945-5201
Mailing Address - Fax:605-945-5094
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:AVERA MEDICAL GROUP PIERRE
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-945-5201
Practice Address - Fax:605-945-5094
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4843207V00000X
SDSD4843207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6200902Medicaid
SD103038Medicare PIN
SD7808Medicare ID - Type Unspecified
SD6200900Medicare ID - Type Unspecified
SDF79737Medicare UPIN