Provider Demographics
NPI:1265957195
Name:THIEMS, SHELBY KAY
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:KAY
Last Name:THIEMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1164 STONE RD
Mailing Address - Street 2:
Mailing Address - City:NEW DOUGLAS
Mailing Address - State:IL
Mailing Address - Zip Code:62074-4003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 S SMILEY ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2316
Practice Address - Country:US
Practice Address - Phone:618-632-3507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
22OtherRESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS