Provider Demographics
NPI:1922051010
Name:SHELTON, WANDA S (FNP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:S
Last Name:SHELTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650
Mailing Address - Country:US
Mailing Address - Phone:423-743-6141
Mailing Address - Fax:423-743-1083
Practice Address - Street 1:105 GAY ST
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650
Practice Address - Country:US
Practice Address - Phone:423-743-6141
Practice Address - Fax:423-743-1083
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000049950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380594Medicaid
P32661Medicare UPIN
TN3913186Medicare ID - Type Unspecified