Healthcare Provider Details

I. General information

NPI: 1235967910
Provider Name (Legal Business Name): JAMIE LYN SHELLEY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 HAWTHORNE ST
ALEXANDRIA MN
56308-1815
US

IV. Provider business mailing address

621 HAWTHORNE ST
ALEXANDRIA MN
56308-1815
US

V. Phone/Fax

Practice location:
  • Phone: 320-335-1709
  • Fax:
Mailing address:
  • Phone: 320-287-1531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number588
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: