Provider Demographics
NPI:1295168581
Name:BLUM, SHELBY NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:NICOLE
Last Name:BLUM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:NICOLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1380 N INDIAN HILL CIR
Mailing Address - Street 2:APT C
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-5775
Mailing Address - Country:US
Mailing Address - Phone:612-803-0582
Mailing Address - Fax:
Practice Address - Street 1:1700 E BOGARD RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6563
Practice Address - Country:US
Practice Address - Phone:907-376-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist