Healthcare Provider Details

I. General information

NPI: 1134813009
Provider Name (Legal Business Name): ANGELIA SHELL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 05/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 MO 51
MARBLE HILL MO
63764
US

IV. Provider business mailing address

15290 STATE HIGHWAY 51
ADVANCE MO
63730-7151
US

V. Phone/Fax

Practice location:
  • Phone: 573-979-4414
  • Fax:
Mailing address:
  • Phone: 573-979-4414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2016026782
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: