Provider Demographics
NPI:1326801937
Name:MANGEOT, SHELBY LOUISE
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LOUISE
Last Name:MANGEOT
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 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:411 E CHESTNUT ST # 5A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1713
Practice Address - Country:US
Practice Address - Phone:502-588-7450
Practice Address - Fax:502-588-7228
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1158294163WP0200X
390200000X
KY4027818363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4027818OtherSTATE LICENSE