Healthcare Provider Details

I. General information

NPI: 1922718600
Provider Name (Legal Business Name): SHELLA BAKER TREGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1174 E HOME RD
SPRINGFIELD OH
45503-2726
US

IV. Provider business mailing address

543 E COUNTY LINE RD
SPRINGFIELD OH
45502-9565
US

V. Phone/Fax

Practice location:
  • Phone: 937-398-0354
  • Fax:
Mailing address:
  • Phone: 937-789-7262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0032839
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: