Provider Demographics
NPI:1295139913
Name:BANDY, SHELLEY PHILLIPS (CMF,CMF,COF)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:PHILLIPS
Last Name:BANDY
Suffix:
Gender:F
Credentials:CMF,CMF,COF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-4306
Mailing Address - Country:US
Mailing Address - Phone:252-773-0904
Mailing Address - Fax:252-565-1733
Practice Address - Street 1:306 PENNY LN
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-4306
Practice Address - Country:US
Practice Address - Phone:252-773-0904
Practice Address - Fax:252-565-1733
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC51438332BC3200X, 332B00000X, 332BD1200X, 332BP3500X, 332BX2000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1295280139Medicaid
NC1295280139OtherBLUE CROSS AND BLUE SHIELD NC
NC1295280139OtherMEDICAID
NC1295280139OtherBLUE CROSS AND BLUE SHIELD SC