Provider Demographics
NPI:1124860184
Name:BURRUSS, SHELBY NICOLE
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:NICOLE
Last Name:BURRUSS
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 1:759 SUMMERSVILLE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT NEBO
Mailing Address - State:WV
Mailing Address - Zip Code:26679-9203
Mailing Address - Country:US
Mailing Address - Phone:304-640-6417
Mailing Address - Fax:
Practice Address - Street 1:759 SUMMERSVILLE LAKE RD
Practice Address - Street 2:
Practice Address - City:MOUNT NEBO
Practice Address - State:WV
Practice Address - Zip Code:26679-9203
Practice Address - Country:US
Practice Address - Phone:304-640-6417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV100272622246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant