Provider Demographics
NPI:1659455509
Name:URBAN, SHELLY (PT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:URBAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 SE DELAWARE AVE
Mailing Address - Street 2:SUITE M
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-4011
Mailing Address - Country:US
Mailing Address - Phone:515-963-8723
Mailing Address - Fax:515-963-8755
Practice Address - Street 1:1555 SE DELAWARE AVE
Practice Address - Street 2:SUITE M
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-4011
Practice Address - Country:US
Practice Address - Phone:515-963-8723
Practice Address - Fax:515-963-8755
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3345225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665430Medicaid
IA166583Medicare ID - Type UnspecifiedC. IA MEDICARE #