Healthcare Provider Details

I. General information

NPI: 1457194953
Provider Name (Legal Business Name): MRS. SHELLI LYNN VAN ROEKEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 11TH ST
HAWARDEN IA
51023-1903
US

IV. Provider business mailing address

4938 GOLDFINCH AVE
MAURICE IA
51036-7554
US

V. Phone/Fax

Practice location:
  • Phone: 712-551-3100
  • Fax:
Mailing address:
  • Phone: 712-899-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number130982
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberA179839
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: