Healthcare Provider Details

I. General information

NPI: 1194544726
Provider Name (Legal Business Name): SHELLY LYNN HULSEY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 10/09/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 MATTOX DR
SULLIVAN MO
63080-2365
US

IV. Provider business mailing address

527 HULSEY PATH
ROBERTSVILLE MO
63072-2216
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-1005
  • Fax:
Mailing address:
  • Phone: 314-604-8449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number2014022750
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: