Provider Demographics
NPI:1740281765
Name:SHELLY, JEANETTE (RN, MS, FNP, NP-C)
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:
Last Name:SHELLY
Suffix:
Gender:F
Credentials:RN, MS, FNP, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 EASTMONT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3322
Mailing Address - Country:US
Mailing Address - Phone:949-857-0283
Mailing Address - Fax:
Practice Address - Street 1:1200 N MAIN ST
Practice Address - Street 2:SUITE 650
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-3640
Practice Address - Country:US
Practice Address - Phone:714-824-8140
Practice Address - Fax:714-824-8141
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA177200; NP 8770363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS97534Medicare UPIN