Provider Demographics
NPI:1629710397
Name:SHELLEY, MANDY SUE (DO)
Entity type:Individual
Prefix:DR
First Name:MANDY
Middle Name:SUE
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 RADERS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24991-7008
Mailing Address - Country:US
Mailing Address - Phone:502-348-5968
Mailing Address - Fax:
Practice Address - Street 1:3615 E JOHN ROWAN BLVD STE 104
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-3264
Practice Address - Country:US
Practice Address - Phone:502-348-5968
Practice Address - Fax:270-706-5802
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY06008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program