Provider Demographics
NPI:1710611603
Name:PATTERSON, SHELBY (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:
Other - Last Name:GILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18591 S CYPRESS CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-4615
Mailing Address - Country:US
Mailing Address - Phone:574-309-4594
Mailing Address - Fax:
Practice Address - Street 1:1815 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-15
Last Update Date:2022-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28220040A163WP0200X
IN71012807A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300067413Medicaid