Healthcare Provider Details

I. General information

NPI: 1629554720
Provider Name (Legal Business Name): SHELLIE JACLYN MONTES FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18092 WIKA RD STE 130
APPLE VALLEY CA
92307-2132
US

IV. Provider business mailing address

12432 DEL SUR ST
VICTORVILLE CA
92392-4851
US

V. Phone/Fax

Practice location:
  • Phone: 442-292-2358
  • Fax:
Mailing address:
  • Phone: 928-551-5354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95026695
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95021427
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: