Provider Demographics
NPI:1922318484
Name:STILES, SHELLY POPHAM (APRN)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:POPHAM
Last Name:STILES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4202
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:120 EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4201
Practice Address - Country:US
Practice Address - Phone:502-855-7200
Practice Address - Fax:502-855-7201
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003523A363LF0000X
KY3006663363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
121043OtherSIHO PROVIDER ID NUMBER
1890913OtherHUMANA PROVIDER ID NUMBER
CS2026700142OtherCARESOURCE PROVIDER ID NUMBER
000001401850OtherANTHEM PROVIDER ID NUMBER
4315911OtherCIGNA PROVIDER ID NUMBER
KY2254146OtherWELLCARE OF KENTUCKY PROVIDER ID NUMBER
KY7100145300Medicaid
KY93601KYIPOtherAETNA BETTER HEALTH OF KENTUCKY PROVIDER ID NUMBER
IN300027468Medicaid