Healthcare Provider Details

I. General information

NPI: 1770978074
Provider Name (Legal Business Name): SHELLY DIANE SEDBERRY D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W 32ND ST BLDG C
JOPLIN MO
64804
US

IV. Provider business mailing address

PO BOX 4427
JOPLIN MO
64803-4427
US

V. Phone/Fax

Practice location:
  • Phone: 405-819-8013
  • Fax:
Mailing address:
  • Phone: 417-622-0648
  • Fax: 417-622-0497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number12-00438
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2018010120
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: