Provider Demographics
NPI:1750496253
Name:SHELL, AMY E (FNP- BC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:SHELL
Suffix:
Gender:F
Credentials:FNP- BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 REMINGTON PL
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-8076
Mailing Address - Country:US
Mailing Address - Phone:573-300-5905
Mailing Address - Fax:573-686-8785
Practice Address - Street 1:2400 LUCY LEE PKWY STE A
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2427
Practice Address - Country:US
Practice Address - Phone:573-686-1144
Practice Address - Fax:573-686-3312
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000162310363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428744007Medicaid
MO824643944Medicare ID - Type Unspecified
MO428744007Medicaid