Provider Demographics
NPI:1811366552
Name:SHELLNUTT, MARY C (APRN, AGCNS-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:C
Last Name:SHELLNUTT
Suffix:
Gender:F
Credentials:APRN, AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SAUNDERS AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-7524
Mailing Address - Country:US
Mailing Address - Phone:469-247-2365
Mailing Address - Fax:
Practice Address - Street 1:501 SAUNDERS AVE STE 320
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-7524
Practice Address - Country:US
Practice Address - Phone:903-606-5140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128617364SA2200X, 364S00000X, 364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology