Provider Demographics
NPI:1891829008
Name:HISLEY, SHELTON M (OB GYN NP)
Entity Type:Individual
Prefix:
First Name:SHELTON
Middle Name:M
Last Name:HISLEY
Suffix:
Gender:F
Credentials:OB GYN NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4336 LOBLOLLY CIR SE
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-8491
Mailing Address - Country:US
Mailing Address - Phone:910-253-3353
Mailing Address - Fax:
Practice Address - Street 1:25 COURTHOUSE DR. NE
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422
Practice Address - Country:US
Practice Address - Phone:910-253-2250
Practice Address - Fax:910-253-2370
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC051074363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology