Provider Demographics
NPI:1932562386
Name:SERFOSS, SHELLLY
Entity Type:Individual
Prefix:
First Name:SHELLLY
Middle Name:
Last Name:SERFOSS
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 1:515 E DRAKE RD APT A114
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4630
Mailing Address - Country:US
Mailing Address - Phone:970-380-2711
Mailing Address - Fax:
Practice Address - Street 1:515 E DRAKE RD APT A114
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4630
Practice Address - Country:US
Practice Address - Phone:970-380-2711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-03
Last Update Date:2016-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor