Provider Demographics
NPI:1750409314
Name:LITTLETON, SHELLEY LYNNE (PA-C)
Entity type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:LYNNE
Last Name:LITTLETON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SHELLEY
Other - Middle Name:LYNNE
Other - Last Name:KAMSICKAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:250 N ORTONVILLE RD STE C
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-8308
Mailing Address - Country:US
Mailing Address - Phone:248-793-7113
Mailing Address - Fax:
Practice Address - Street 1:250 N ORTONVILLE RD STE C
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-8308
Practice Address - Country:US
Practice Address - Phone:248-793-7113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003410363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISL003410OtherBCBS STATE LICENSE
MI0652511990OtherBCBSM IND PIN
P33590009Medicare PIN