Provider Demographics
NPI:1104422609
Name:PROSS, SHELLY JO
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:JO
Last Name:PROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:VELVA
Mailing Address - State:ND
Mailing Address - Zip Code:58790-0337
Mailing Address - Country:US
Mailing Address - Phone:701-340-2165
Mailing Address - Fax:
Practice Address - Street 1:505 TRUAX AVE W
Practice Address - Street 2:
Practice Address - City:VELVA
Practice Address - State:ND
Practice Address - Zip Code:58790-0337
Practice Address - Country:US
Practice Address - Phone:701-340-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant