Provider Demographics
NPI:1790279230
Name:SELLS, CODY W
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:W
Last Name:SELLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ROLLA GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3950
Mailing Address - Country:US
Mailing Address - Phone:573-201-9232
Mailing Address - Fax:
Practice Address - Street 1:1000 GW LN
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2339
Practice Address - Country:US
Practice Address - Phone:573-774-2715
Practice Address - Fax:573-202-2410
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018024334363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily