Healthcare Provider Details

I. General information

NPI: 1528531175
Provider Name (Legal Business Name): STEPHANIE MARISA SHELBY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W 95TH ST STE 270
PRAIRIE VILLAGE KS
66207-3300
US

IV. Provider business mailing address

5000 W 95TH ST STE 270
PRAIRIE VILLAGE KS
66207-3300
US

V. Phone/Fax

Practice location:
  • Phone: 913-341-4141
  • Fax: 913-341-4432
Mailing address:
  • Phone: 913-341-4141
  • Fax: 913-341-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number61987
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: