Healthcare Provider Details

I. General information

NPI: 1275615593
Provider Name (Legal Business Name): SHELLY A BREYEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 SKYLINE BLVD
CLOQUET MN
55720-1164
US

IV. Provider business mailing address

417 SKYLINE BLVD
CLOQUET MN
55720-1164
US

V. Phone/Fax

Practice location:
  • Phone: 218-879-1271
  • Fax: 218-879-8904
Mailing address:
  • Phone: 218-879-1271
  • Fax: 218-879-8904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37600
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: