Provider Demographics
NPI:1275356164
Name:DAVIS, SHELLY R (MN BSN-RN PHN CCHP)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MN BSN-RN PHN CCHP
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:R
Other - Last Name:BARTLETT, WYATT, JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:810 S MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097
Mailing Address - Country:US
Mailing Address - Phone:530-841-2140
Mailing Address - Fax:
Practice Address - Street 1:810 S MAIN STREET
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097
Practice Address - Country:US
Practice Address - Phone:530-841-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA850299163W00000X
CA546189163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse