Provider Demographics
NPI:1104465558
Name:CRANE, SHELLY (AGNP-C)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:CRANE
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 N GOVERNMENT WAY # 294
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-3751
Mailing Address - Country:US
Mailing Address - Phone:208-791-3391
Mailing Address - Fax:
Practice Address - Street 1:915 W EMMA AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2531
Practice Address - Country:US
Practice Address - Phone:208-791-3391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID39760363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care