Healthcare Provider Details

I. General information

NPI: 1396008843
Provider Name (Legal Business Name): SHELLY PETRY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 WEST WILLOW STREET BUILDING A
LAFAYETTE LA
70501
US

IV. Provider business mailing address

220 W. WILLOW ST. BLDG.A
LAFAYETTE LA
70501
US

V. Phone/Fax

Practice location:
  • Phone: 337-262-5616
  • Fax: 337-262-1310
Mailing address:
  • Phone: 337-262-5616
  • Fax: 337-262-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN082564
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: