Healthcare Provider Details

I. General information

NPI: 1407254808
Provider Name (Legal Business Name): SHELLEY NICOLE REAVES APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2014
Last Update Date: 10/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9159 TELECOM DR
MILAN TN
38358
US

IV. Provider business mailing address

92 BEND RD
DYERSBURG TN
38024-8600
US

V. Phone/Fax

Practice location:
  • Phone: 731-686-4212
  • Fax: 731-723-1302
Mailing address:
  • Phone: 731-445-0127
  • Fax: 731-723-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number19505
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number161142
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: