Provider Demographics
NPI:1790848364
Name:SHELLEY, SANDRA D (CRNA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4509 WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-5244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3911 HIGHWAY 17 # B
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5014
Practice Address - Country:US
Practice Address - Phone:843-651-8211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18465367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00395317OtherRR MEDICARE
SC204185222OtherBCBS OF SC
SC204185222OtherTRICARE
SCGP4376Medicaid
SCAN0060Medicaid
SCDE5998OtherRR MEDICARE
SCP00395317OtherRR MEDICARE
SCAN0060Medicaid
SCQ27561Medicare UPIN
SCDE5998OtherRR MEDICARE
SCGP4376Medicaid