Healthcare Provider Details

I. General information

NPI: 1225452162
Provider Name (Legal Business Name): JOSHUA MICHAEL SHELLEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2014
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3307 HALLIDAY AVE
SAINT LOUIS MO
63118-1211
US

IV. Provider business mailing address

3307 HALLIDAY AVE
SAINT LOUIS MO
63118-1211
US

V. Phone/Fax

Practice location:
  • Phone: 314-368-0286
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2014011359
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2005021478
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: