Healthcare Provider Details

I. General information

NPI: 1891016358
Provider Name (Legal Business Name): SHELLY M LYNCH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLY M SULLIVAN FNP-C

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 02/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 BURKARTH RD
WARRENSBURG MO
64093-3103
US

IV. Provider business mailing address

1200 W 22ND ST
HIGGINSVILLE MO
64037-1420
US

V. Phone/Fax

Practice location:
  • Phone: 660-747-7751
  • Fax: 660-747-8398
Mailing address:
  • Phone: 660-584-7751
  • Fax: 660-584-8261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1499522042
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2010011279
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: