Healthcare Provider Details

I. General information

NPI: 1407088727
Provider Name (Legal Business Name): VICTORIA J SHELLEM CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 12/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEDICAL PKWY SUITE 200
ANNAPOLIS MD
21401-3742
US

IV. Provider business mailing address

PO BOX 12622
BELFAST ME
04915-4017
US

V. Phone/Fax

Practice location:
  • Phone: 443-481-5300
  • Fax: 443-481-6705
Mailing address:
  • Phone: 443-481-6573
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR153442
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: