Healthcare Provider Details

I. General information

NPI: 1972015618
Provider Name (Legal Business Name): BRIANNA BERTINA SHELLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 S 108TH ST
GREENFIELD WI
53228-2505
US

IV. Provider business mailing address

4420 S 108TH ST
GREENFIELD WI
53228-2505
US

V. Phone/Fax

Practice location:
  • Phone: 414-871-6122
  • Fax: 414-871-2552
Mailing address:
  • Phone: 414-871-6122
  • Fax: 414-871-2552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: