Healthcare Provider Details

I. General information

NPI: 1881314854
Provider Name (Legal Business Name): SHELBY WHITING RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELBY ICE RN

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4612 N 28TH ST
PHOENIX AZ
85016-4999
US

IV. Provider business mailing address

4539 W BEAUTIFUL LN
LAVEEN AZ
85339-7318
US

V. Phone/Fax

Practice location:
  • Phone: 602-764-7000
  • Fax:
Mailing address:
  • Phone: 661-427-8941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number261090
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: