Healthcare Provider Details

I. General information

NPI: 1982204715
Provider Name (Legal Business Name): AMANDA L SHELBY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 POQUONNOCK RD
GROTON CT
06340-4257
US

IV. Provider business mailing address

110 OLD KENT RD N
TOLLAND CT
06084-3328
US

V. Phone/Fax

Practice location:
  • Phone: 860-446-0144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9210
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number137290
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2309851
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: