Healthcare Provider Details

I. General information

NPI: 1104367499
Provider Name (Legal Business Name): PATRISHA SHELLEY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E CHESTNUT ST UNIT 690
LOUISVILLE KY
40202-5706
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-4710
  • Fax:
Mailing address:
  • Phone: 502-852-2840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberUO5380
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS16809
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04922
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number04922
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: