MEDICARE: CAROL M SHELLEY FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP109447	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124029731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL M SHELLEY FNP-C

Provider Business Mailing Address
First Line	:	1004 WINSCOTT RD
Second Line	:
City	:	BENBROOK
State	:	TX
Zip	:	76126-2776
Country	:	US
Telephone Number	:	817-249-0111
Fax Number	:	817-249-0110

Provider Business Practice Location Address
First Line	:	1004 WINSCOTT RD
Second Line	:
City	:	BENBROOK
State	:	TX
Zip	:	76126-2776
Country	:	US
Telephone Number	:	817-249-0111
Fax Number	:	817-249-0110

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	03/21/2017

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