Healthcare Provider Details

I. General information

NPI: 1609789783
Provider Name (Legal Business Name): AVERY LEE SHELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 WEDGEWOOD DR APT A12
FAIRBANKS AK
99701-1617
US

IV. Provider business mailing address

307 WEDGEWOOD DR APT A12
FAIRBANKS AK
99701-1617
US

V. Phone/Fax

Practice location:
  • Phone: 907-474-0890
  • Fax:
Mailing address:
  • Phone: 907-474-0890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: