Provider Demographics
NPI:1992022719
Name:SHELLY, ALICIA (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:
Last Name:SHELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 MEDICAL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7218
Mailing Address - Country:US
Mailing Address - Phone:770-960-8855
Mailing Address - Fax:
Practice Address - Street 1:235 MEDICAL BLVD STE B
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7218
Practice Address - Country:US
Practice Address - Phone:770-960-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME137755207R00000X
GA69712207R00000X
VA0101266249207R00000X
NY296213207R00000X
CAA121267207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine