Healthcare Provider Details

I. General information

NPI: 1477474435
Provider Name (Legal Business Name): ALICE E SHELLY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3437 CAROLINE ST
SAINT LOUIS MO
63104-1111
US

IV. Provider business mailing address

31036 POST OAK TRL
BOERNE TX
78015-4149
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-2570
  • Fax:
Mailing address:
  • Phone:
  • 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: