Healthcare Provider Details

I. General information

NPI: 1386342509
Provider Name (Legal Business Name): SHELLI RENEE CRUZ CCP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHELLI RENEE RATLIFF

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 RUSTIC WOODS CT
BEDFORD TX
76021-4064
US

IV. Provider business mailing address

3105 RUSTIC WOODS CT
BEDFORD TX
76021-4064
US

V. Phone/Fax

Practice location:
  • Phone: 972-400-2824
  • Fax:
Mailing address:
  • Phone: 972-400-2824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License NumberFPF00001052
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: