Healthcare Provider Details

I. General information

NPI: 1255101952
Provider Name (Legal Business Name): SHELBY NICOLE HART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2551
US

IV. Provider business mailing address

1922 7TH AVE APT 2
HUNTINGTON WV
25703-1697
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-1774
  • Fax:
Mailing address:
  • Phone: 989-614-1026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: