Provider Demographics
NPI:1821192048
Name:HUDSON, SHELLY D
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:D
Last Name:HUDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 HACKBERRY LN
Mailing Address - Street 2:
Mailing Address - City:HARVIELL
Mailing Address - State:MO
Mailing Address - Zip Code:63945-7115
Mailing Address - Country:US
Mailing Address - Phone:573-399-2669
Mailing Address - Fax:
Practice Address - Street 1:1500 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3318
Practice Address - Country:US
Practice Address - Phone:573-686-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016003074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily