=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861209074
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLEY LEANN TINNEL RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2024
-----------------------------------------------------
Last Update Date | 12/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 GRANT ST
-----------------------------------------------------
City | GARY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46402-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-886-4710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11551 N 900 W
-----------------------------------------------------
City | DEMOTTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46310-8235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-405-4675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WE0003X
-----------------------------------------------------
Taxonomy Name | Emergency Registered Nurse
-----------------------------------------------------
License Number | 28234971A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------