=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003795667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAIME LEE BALEY ELLIOTT-SHIELDS PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2025
-----------------------------------------------------
Last Update Date | 08/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1708 DELL RANGE BLVD
-----------------------------------------------------
City | CHEYENNE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82009-4945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-829-3118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1629 COPPERVILLE RD
-----------------------------------------------------
City | CHEYENNE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82001-6561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-531-9491
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0025333
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 4631
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------