Provider Demographics
NPI:1427261452
Name:SUPAN, SHELLY D
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:D
Last Name:SUPAN
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 1:3036 COTTAGE LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-6000
Mailing Address - Country:US
Mailing Address - Phone:651-235-9955
Mailing Address - Fax:
Practice Address - Street 1:8320 CITY CENTRE DR
Practice Address - Street 2:SUITE G
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3382
Practice Address - Country:US
Practice Address - Phone:651-738-9888
Practice Address - Fax:651-738-9889
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102272225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist