Provider Demographics
NPI:1770087058
Name:SHELLEY, ANNA RAE (LGC)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:RAE
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:LGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 13TH AVE NE APT 310
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2091
Mailing Address - Country:US
Mailing Address - Phone:515-370-1380
Mailing Address - Fax:
Practice Address - Street 1:1575 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1126
Practice Address - Country:US
Practice Address - Phone:651-326-7610
Practice Address - Fax:651-326-7050
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN170300000X
MN1219170300000X
170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS