Healthcare Provider Details

I. General information

NPI: 1619706041
Provider Name (Legal Business Name): KELLY SHOUSE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 COLORADO AVE
TURLOCK CA
95382-2011
US

IV. Provider business mailing address

3812 SUNDANCE LAKE CT
MODESTO CA
95355-7309
US

V. Phone/Fax

Practice location:
  • Phone: 209-850-3500
  • Fax:
Mailing address:
  • Phone: 850-530-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95030512
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: