MEDICARE: MRS. SHELLY S BOONE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	28144111A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21358	OTHER	IN	PHP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000000504327	OTHER	IN	BCBS

General Provider Information

NPI Number	:	1093722613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHELLY S BOONE NP

Provider Business Mailing Address
First Line	:	11109 PARKVIEW PLAZA DR # 117
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:	260-266-6013
Fax Number	:

Provider Business Practice Location Address
First Line	:	1025 MACHESTER AVE
Second Line	:
City	:	WABASH
State	:	IN
Zip	:	46992-1496
Country	:	US
Telephone Number	:	260-563-7421
Fax Number	:	260-563-7725

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	10/17/2022

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