Provider Demographics
NPI:1790344166
Name:EASTRIDGE, SHELLY RAE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RAE
Last Name:EASTRIDGE
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 W COLLIN RAYE DR
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-2946
Mailing Address - Country:US
Mailing Address - Phone:870-518-4388
Mailing Address - Fax:870-518-4350
Practice Address - Street 1:1357 W COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-2946
Practice Address - Country:US
Practice Address - Phone:870-518-4388
Practice Address - Fax:870-518-4350
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR120295363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily