Provider Demographics
NPI:1770193161
Name:SHOCKLEY, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:SHOCKLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 PLATTE FALLS RD STE C
Mailing Address - Street 2:
Mailing Address - City:PLATTE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64079-7323
Mailing Address - Country:US
Mailing Address - Phone:816-431-2150
Mailing Address - Fax:
Practice Address - Street 1:1306 PLATTE FALLS RD STE C
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-7323
Practice Address - Country:US
Practice Address - Phone:816-431-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-79528-072363LF0000X
MO2020016732363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily