Provider Demographics
NPI:1205176476
Name:GREEN, SHELLY MARIE (CRNA)
Entity type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:MARIE
Other - Last Name:SIEBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 1155
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59103-1155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3409
Practice Address - Country:US
Practice Address - Phone:307-587-2139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS146502367500000X
WY35180-1385367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered