Provider Demographics
NPI:1790140150
Name:CRADER, SHELLY C (APRN)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:C
Last Name:CRADER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:C
Other - Last Name:DARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:2318 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4436
Mailing Address - Country:US
Mailing Address - Phone:316-262-3611
Mailing Address - Fax:316-262-0318
Practice Address - Street 1:2318 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4436
Practice Address - Country:US
Practice Address - Phone:316-262-3611
Practice Address - Fax:316-262-0318
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-77054363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner