Provider Demographics
NPI:1184430167
Name:VANENGEL, SHELBY (CPHT, EXCPHT)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:VANENGEL
Suffix:
Gender:
Credentials:CPHT, EXCPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:WI
Mailing Address - Zip Code:53594-1129
Mailing Address - Country:US
Mailing Address - Phone:608-807-6072
Mailing Address - Fax:
Practice Address - Street 1:302 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-9827
Practice Address - Country:US
Practice Address - Phone:608-837-5949
Practice Address - Fax:608-825-3253
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
WI220131-41183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No174H00000XOther Service ProvidersHealth Educator