Provider Demographics
NPI:1881617116
Name:SHELTON, PENNY (ACNP-C)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:SHELTON
Suffix:
Gender:F
Credentials:ACNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5044
Mailing Address - Country:US
Mailing Address - Phone:573-472-6001
Mailing Address - Fax:573-472-6006
Practice Address - Street 1:1008 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5044
Practice Address - Country:US
Practice Address - Phone:573-472-6001
Practice Address - Fax:573-472-6006
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102298207R00000X, 363LA2100X
MO2011035557363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q42379Medicare UPIN
Q42379Medicare UPIN