Provider Demographics
NPI:1487339024
Name:LOPEZ, SHELBY NICOLE
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:NICOLE
Last Name:LOPEZ
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 1:1013 N AZURE CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-9438
Mailing Address - Country:US
Mailing Address - Phone:316-207-9655
Mailing Address - Fax:
Practice Address - Street 1:1701 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-7500
Practice Address - Country:US
Practice Address - Phone:620-231-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-152169-051363LS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool