Healthcare Provider Details

I. General information

NPI: 1780255240
Provider Name (Legal Business Name): ADRIA SHELLEY CAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 STATE ST
NEW ALBANY IN
47150-4990
US

IV. Provider business mailing address

1221 E BROADWAY APT 223
LOUISVILLE KY
40204-2537
US

V. Phone/Fax

Practice location:
  • Phone: 920-277-9970
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number75000081A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: